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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/surgicalanatomyoOOmcgr 


Surgical  Anatomy 


Operative  Surgery 


For  Students  and  Practitioners 


JOHN   J.  McGRATH,  M.D. 

Professor  or  Surgical  Anatomy  and  Operative  Surgery  at  the  New  York  Post-graduate  Medical 

School,  Visiting  Surgeon  to  the  Harlem  Hospital,  and  Assistant  Visiting 

Surgeon  to  the  Columbus  Hospital,  New  York. 


Olttb  227  Illustrations,  including  Colors  and  Balf-tone$ 


Philadelphia 

F.  A.   DAVIS   COMPANY,  PUBLISHERS 

1902 


COPYRIGHT,  1902, 

BT 

F.  A.   DAVIS  COMPANY. 

(Registered  at  Stationers'  Hall,  London,  Eng.] 


Philadelphia,  Pa.,  U.  S.  A.: 

The  Medical  Bulletin  Printing-house, 

1914-16  Cherry  Street. 


PREFACE. 

In  this  volume  an  endeavor  has  "been  made  to  combine, 
in  a  practical  manner,  the  subjects  of  surgical  anatomy  and 
operative  surgery,  because  a  knowledge  of  the  one  is  essential 
to  the  proper  study  of  the  other. 

Diagrammatic  drawings  have  been  used  largely  for  the 
purpose  of  illustration,  because  these,  in  my  judgment,  are 
the  most  satisfactory  for  teaching. 

An  effort  has  been  made  to  exclude  all  those  anatomical 
considerations  that  are  purely  technical  and  not  of  practical 
value  in  the  performance  of  surgical  operations. 

The  arrangement  of  the  subject  has  been  made  in  accord- 
ance with  the  plan  followed  in  my  courses  in  operative  surgery 
at  the  Post-graduate  Medical  School. 

John  J.  McGeath. 


CONTENTS. 


PAET  I.  PAGa 

General  Considerations 1-18 

Anaesthesia:  General  anaesthesia,  1;  incomplete  general  anesthesia,  1; 
local  anaesthesia,  Schleich  infiltration  method,  3;  analgesia  by  subarach- 
noid injection  of  cocain,  3. Division  of  Tissues:    Division  of  soft  parts, 

4;    division  of  bone,  5. Hemorrhage:    Means  to  arrest  hemorrhage,   6; 

natural  arrest  of  hemorrhage,   6;     artificial   arrest  of  hemorrhage,   6. 

Suture  of  the  Tissues:  Suture  of  the  skin,  13;  intracuticular  suture,  14; 
suture  of  muscle,  14;  suture  of  tendons,  15;  suture  of  nerves,  15;  suture 
of  bone  and  cartilage,  15;    suture  of  serous  surfaces,   bowel,   etc.,  16. 


PAET  II. 
Head  and  Face 19-117 

Head:    Surgical  anatomy  of  the  head,  19;    of  the  scalp,  19;    of  the  skull, 

20;    of  the  dura  mater,  21;    of  the  pia  mater,  23. Operations  upon  the 

Head:  Trephining,  23;  for  depressed  fracture  of  the  skull,  23;  for  intra- 
cranial  hemorrhage,   25;     craniectomy    (linear   craniotomy),    29. Middle 

Fossa  of  the  Skull:  Anatomy  of  the  middle  fossa,  30;  extirpation  of  Cas- 
serian  ganglion  (Hartley-Krause),  36. Mastoid  Region  and  Ear:  Sur- 
gical anatomy  of  mastoid  region,  39 ;  anatomy  of  the  ear,  41. Opera- 
tions upon  the  Mastoid,  etc.:  Wilde's  incision,  46;  drilling  into  antrum, 
46;  to  open  and  drain  antrum,  46;  for  thrombosis  sigmoid  sinus,  48;  for 
cerebellar  abscess,   50;     for  extradural  abscess   in  middle   fossa,   50;     for 

temporo-sphenoidal   abscess,   51. Face:     Surgical   anatomy   of   face,    51; 

of  skeleton  of  face,  52;    of  mouth,  54;    side  of  face,  58;    pterygo-maxillary 

region,   58. Operations  upon  Face:     Resection  of  upper  jaw,   64;     total 

resection  of  both  superior  maxillae,  69;  to  drain  antrum  of  Highmore,  69; 
resection  of  half  of  lower  jaw,  70;  resection  of  half  of  body  of  lower  jaw, 
73;  resection  of  entire  body  of  lower  jaw,  75;  resection  of  part  of  body  of 
lower  jaw  (in  continuity),  75;  resection  of  part  of  body  of  lower  jaw  (not 
in  continuity),  76;  extirpation  of  Casserian  ganglion  (Rose-Andrews),  76; 
division  of  second  and  third  branches  of  trifacial  nerve  (Kronlein-Liicke), 
79. Congenital  Deformities  of  Face:  Development  of  face,  80;  forma- 
tion of  palate,  88;  teeth,  89;  tongue,  89;  deformities  of  face,  89;  deformi- 
ties in  which  frontal  plate  is  concerned,  91;  lateral  clefts  of  the  upper 
lip,  and  alveolar  process  and  cleft  palate,  91;  median  clefts  and  notches 
of  the  upper  lip,  95;  oblique  facial  clefts,  96;  deformities  in  which  the 
first  visceral  arch  is  concerned,  98;    transverse  facial  clefts,  98;    median 

clefts  of  lower  lip,  lower  jaw,  and  tongue,  98. Operations  for  Harelip, 

Cleft  Palate,  etc.:  Operations  for  harelip,  98;  operations  for  incomplete 
harelip,  100;  operations  for  complete  harelip,  102;  operation  for  single 
complete  harelip  with  cleft  of  alveolar  process  and  advancement  of  the 
intermaxillary  bone,  104;  operation  for  double  harelip  without  a  promi- 
nent advanced  intermaxillary  bone,  104;  operation  for  double  harelip  with 
prominent  advanced  intermaxillary  bone,  105;    operation  for  cleft  palate, 


(V) 


VI  CONTENTS. 

PAGE 

107. Operations  upon  the  Lips:  Excision  of  whole  lower  lip,  111;  res- 
toration of  lower  lip,  112;  Dieffenbach-Jaesche,  112;  Bruns,  113;  Langen- 
beck,  114;  Estlander,  115;  restoration  of  upper  lip,  116;  Estlander,  116; 
Dieffenbach's  Wellenschnitt,  116;    Bruns,  117. 


PAET  III. 
Neck  and  Tongue 118-165 

Surgical  Anatomy  of  Neck:  Deep  cervical  fascia,  118;  back  of  the  neck, 
120;  side  of  the  neck,  120;  anterior  triangle,  122;  posterior  triangle,  122; 
sterno-mastoid  region,  123;  inferior  carotid  triangle,  123;  superior  carotid 
triangle,  125;  submaxillary  triangle,  126;  lingual  triangle,  127;  occipital 
triangle,  127;  subclavian  triangle,  128;  front  of  the  neck,  129;  hyoid 
bone,  130;  suprahyoid  region,  130;  infrahyoid  region,  130;  laryngeal  re- 
gion, 134;  thyroid  gland,  134;  suprasternal  region,  135;  blood-vessels  of 
the  neck,  136;  common  carotid  artery,  136;  internal  carotid  artery,  137; 
external  carotid  artery,  138;    internal  jugular  vein,  139;    subclavian  artery, 

140;    inferior  thyroid  artery,  141;    vertebral  artery,  141. Operations  upon 

the  Neck:  Tracheotomy,  142;  tampon  of  trachea,  142;  high  tracheotomy, 
143;  low  tracheotomy,  144;  median  tracheotomy,  145;  transverse  laryn- 
gotomy,  146;  thyrotomy,  146;  laryngectomy,  148;  extirpation  of  half  of 
the  larynx,  152;  external  oesophagotomy,  152;  ligation  of  blood-vessels, 
153;  common  carotid  artery,  153;  external  carotid  artery,  155;  internal 
carotid  artery,  156;  subclavian  artery,  156;  lingual  artery,  158. Opera- 
tions upon  the  Tongue:  Amputation  of  tongue  (Kocher),  159;  amputation 
of  tongue  (Regnoli-Billroth),  161;  extirpation  of  tongue  through  floor  of 
mouth  with  division  of  lower  jaw,  162;  Sedillot,  162;  Langenbeck,  163; 
Billroth,  164;    extirpation  of  half  of  the  tongue  (Whitehead),  164. 


PAET  IV. 
Thorax 166-204 

Surgical  Anatomy  of  Thoracic  Wall:    Skeleton  of  thorax,  166;    muscles  of 
chest   wall,    169;     fasciae   of  chest,    169;     internal    mammary    artery,    170; 

diaphragm,  171. Regions  of  Chest:    Sternal  region,  172;    upper  anterior 

pectoral  region,  172;  clavicular  region,  173;  infraclavicular  region,  174; 
mammary  regjon  (breast),  175;    lower  anterior  pectoral  region,  177;  lateral 

pectoral    region,    177. Mediastinum    and    Contents:      Pericardium,    178 

heart,  179;  thymus,  182;  arch  of  aorta,  182;  pneumogastric  nerves,  183 
phrenic  nerves,  184;  trachea,  184;  oesophagus,  185;  thoracic  aorta,  187 
vena  azygos,  187;    vena  hemiazygos,  188;    thoracic  duct,  188;    innominate 

artery,  188;    left  common  carotid  and  subclavian  arteries,  188. Pleura: 

Limits  of  pleura  indicated  by  lines  upon  chest  wall,  189;    anterior  edge  of 

pleura,   189;     lower  edge  of  pleura,   190;     dome  of  pleura,   191. Lungs: 

Root  of  lung,  192;    lung,  193. Operations  upon  the  Chest:    Incisions  for 

abscess  of  breast,  194;  extirpation  of  tumors  (fibroids)  from  mammary 
gland,  195;  amputation  of  breast,  195;  amputation  of  breast  (Halsted- 
Meyer),  197;  ligation  of  intercostal  artery,  200;  ligation  of  internal  mam- 
mary artery,  200;  thoracentesis,  201;  thoracotomy,  201;  thoracectomy 
(Estlander),   202;    pleurectomy   (Fowler),   203. 


CONTENTS.  vli 

PAET    V.  PAGE 

Abdomen  and  Back 205-337 

Abdomen:  Diaphragm,  205;  posterior  wall  of  the  abdomen,  206;  antero- 
lateral wall  of  the  abdomen,  207;  superficial  vessels  of  abdominal  wall,  208; 
muscles  of  the  antero-lateral  wall,  208;  fascia  transversalis,  211;  parietal 
peritoneum,  211;  deep  vessels  of  abdominal  wall,  212;  regions  of  the  ab- 
domen, 213. The  Back:    Muscles  of  the  back,  215;    erector  spinse  muscle, 

216;     quadratus   lumborum   muscle,   217;     lumbar  fascia,   217;     psoas-  and 

iliacus  muscles,  218;    spinal  column,  etc.,  218. The  Stomach:    Surgical 

anatomy  of  the  stomach,  221. Operations  upon  the  Stomach:    Gastropli- 

cation,  226;  gastrostomy,  228;  Pyloroplasty  (Heinecke  and  Mikulicz),  231; 
gastrostomy,  232;  von  Hacker,  232;  Ssabanajew  and  Pranck,  233;  Witzel, 
235;    gastrorrhaphy,  237;    pylorectomy,  237;    Billroth,  237;    Murphy  button, 

241;     Kocher,    241;     gastrectomy,    244. The    Small    Intestine:     Surgical 

anatomy  of  the  small  intestine,  247. Operations  upon  the  Small  Intes- 
tine: Enterorrhaphy,  252;  enterectomy,  254;  end-to-end  anastomosis, 
257;  suture,  257;  Mounsell's,  259;  Murphy  button,  261;  Laplace  forceps, 
264;  O'Hara  forceps,  266;  side-to-si.de,  lateral,  approximation,  268;  suture, 
268;  Murphy  button,  271;  McGraw  rubber  suture,  271;  Laplace  forceps, 
272;  O'Hara  forceps,  272;  gastro-enterostomy,  272;  anterior  (Woelfler), 
272;  posterior  (von  Hacker),  276;  Murphy  button,  280;  McGraw's  rubber 
suture,  281;  Laplace  forceps,  283;  O'Hara  forceps,  284. Large  Intes- 
tine and  Vermiform  Appendix:  Surgical  anatomy  of  the  large  intestine, 
etc.,  285;  caecum,  285;  vermiform  appendix,  285;  ascending  colon,  287; 
transverse  colon,  287;  descending  colon,  288;  sigmoid  flexure,  288;  blood- 
supply  of  large  intestine,  288. Operations  upon  Large  Intestine:  Co- 
lostomy, 289;  Maydl,  292;  resection  of  cascum,  295;  end-to-end  anasto- 
mosis,  296;     lateral   anastomosis,   297;     end-to-side,    lateral,   implantation, 

298;    ileo-colostomy,   298;    resection  of  sigmoid  flexure,   298. Operations 

upon  "Vermiform  Appendix:  Appendicectomy,  299;  McBurney  incision, 
300;  Battle  incision,  301;  ligature  without  inversion,  302;  inversion  and 
purse-string,  304;  inversion  (Edebohls),  305;  for  appendicular  abscess, 
306;    for  appendicitis  accompanied  with  general  peritoneal  infection,   309. 

Liver    and    Gall-bladder:     Surgical    anatomy    of    liver,    310;     surgical 

anatomy  of  gall-bladder,  312. Operations  upon  Liver:    Hepatotomy,  314; 

hepatectomy,  315;    injuries  of  liver,  315. Operations  upon  Gall-bladder: 

Aspiration  of  gall-bladder,  315;  cholecystotomy,  315;  cholecystostomy, 
318;  cholecystostomy  in  one  sitting,  318;  cholecystostomy  in  two  sittings, 
320;  cholecystostomy  with  adherent  gall-bladder,  322;  cholecystostomy 
■when  unable  to  draw  gall-bladder  up  into  incision,  322;  cholecyst-enter- 
ostomy,  324;  cholecysto-duodenostomy  with  Murphy  button,  325. Opera- 
tions upon  Gall-ducts:    Choledochotomy,  326;    choledocho-lithectomy,  326; 

choledocho-lithotripsy,  327;    duodenotomy  for  impacted  gall-stone,  327. 

The  Spleen:    Surgical  anatomy  of  spleen,  328. Operations  upon  Spleen: 

Splenotomy,   329;     splenectomy,   330. The   Pancreas:     Surgical   anatomy 

of   the   pancreas,    331;     operations   upon   the   pancreas,    332. Operations 

upon  the   Spinal  Column:     Laminectomy,   332;     lumbar   puncture,   334. 


PART  VI. 
The  Rectum 338-361 

Surgical  anatomy  of  the  rectum,   338;     sacrum,   338;     coccyx,   339;     rectum, 

339. Operations    upon    the   Rectum:     Dilatation    of   the    sphincter,    342; 

fistula  in  ano,  342;    for  complete  fistula,  343;    for  incomplete  fistula,  344; 
hemorrhoids,    344;     ligation   and   excision,    345;     clamp   and   cautery,   346; 


viii  CONTENTS. 

PAGE 

excision  of  part  of  rectal  wall,  346;  innocent  rectal  polypi,  348;  extirpa- 
tion of  rectum  (Volkmann),  348;  resection  of  rectum  (Dieffenbach),  351; 
resection  and  amputation  of  rectum  through  sacral  route  (Kraske),  353; 
for  resection  of  rectum,   353;     for  amputation  of  rectum,   361. 


PAET  VII. 
Heenta,  Spekmatic  Coed,  Testes,  etc 362-402 

Surgical  anatomy  of  groin,  362;  superficial  layer  of  superficial  fascia,  362; 
lymphatic  glands,  363;  deep  layer  of  superficial  fascia,  363;  inguinal  re- 
gion, 363;  descent  of  the  testes,  369;  femoral  region,  372;  study  of  in- 
guinal and  femoral  region  from  within  the  abdomen,  375;    inguinal  region, 

375;    femoral  region,  378. Operations  for  Hernia:    Herniotomy,  380;    for 

inguinal  hernia    (Bassini),    383;     for   inguinal  hernia    (Halsted),    389;     for 

femoral   hernia,    392. Spermatic   Cord,    Scrotum,    etc. :     Spermatic   cord, 

393;    scrotum,  394;    testes,  394;    ejaculatory  ducts,  395. Operations  upon 

Spermatic  Cord,  Scrotum,  etc.:  For  varicocele,  395;  for  hydrocele,  397; 
castration,  401. 

PAET  VIII. 
Ueinaey  System 403-436 

Kidneys:  Surgical  anatomy  of  kidney,  403. Operations  upon  the  Kid- 
ney: Nephropexy,  404;  nephropexy  (Edebohls),  407;  nephrotomy,  410; 
nephrolithotomy,  411;  nephrectomy,  411;  decortication  of  kidney  (Ede- 
bohls),  412. Bladder:     Surgical  anatomy   of  bladder,   413. Operations 

upon  Bladder:     Suprapubic  cystotomy,  415;    puncture  of  bladder,   418. 

Penis:    Surgical  anatomy  of  the  penis,  418. Operations  upon  the  Penis: 

Forcible  dilatation  of  prepuce,  419;    dorsal  section,  419;    circumcision,  421; 

circumcision  with  clamp,  422;    amputation  of  penis,  422. Perineum  and 

Ischio-rectal    Region:     Floor   of   pelvis    from   without,    424;     ischio-rectal 

region,  425;    perineum,  426;    pelvic  cavity  from  within,  428. Operations 

upon  Perineum,  etc.:  Perineal  section  with  a  guide,  430;  perineal  sec- 
tion without  a  guide,  431;  median  lithotomy,  432;  lateral  lithotomy,  433; 
Prostatectomy  (McGill-Fuller),  433;  prostatectomy  (Alexander),  434; 
prostatotomy  (Bottini),  435. 


PAET  IX. 
The  Uppee  Exteemity 437-481 

The  Axilla:    The  axilla,  437;    the  axillary  artery,  437. The  Arm:    Vessels 

of  the  arm,  440;  the  brachial  artery,  440;  the  radial  artery,  442;  the 
ulnar  artery,   443;    musculo-spiral  nerve,   445;    median  nerve,   445;     ulnar 

nerve,  445. The  Hand:     Nerve-supply  of  the  hand,   446;    ligations,  446; 

axillary,  446;  brachial,  447;  radial,  449;  ulnar,  449. Amputations,  Re- 
sections, etc.:  Surgical  anatomy  of  hand,  449;  phalango-phalangeal  joints, 
449;  metacarpo-phalangeal  joints,  450;  exarticulation  of  the  finger  at  the 
phalango-phalangeal  joint,  450;  exarticulation  of  finger  at  the  metacarpo- 
phalangeal joint,  452;  exarticulation  of  hand  at  the  carpo-metacarpal 
articulation,  453;  surgical  anatomy  of  wrist-joint,  455;  exarticulation  of 
hand  at  wrist-joint,  456;  amputation  through  forearm,  457;  surgical  anat- 
omy of   elbow- joint,   458;     exarticulation  of   forearm   at   elbow-joint,   460; 


CONTENTS.  ix 

PAGE 

amputation  of  arm,  461;  surgical  anatomy  of  shoulder-joint,  463;  exar- 
ticulation  at  shoulder-joint  (Spence),  465;  exarticulation  at  shoulder- 
joint   (Esmarch),  467;     exarticulation  at  shoulder- joint  with   deltoid   flap, 

469. Resections:    Wrist-joint,  472;    elbow  (Langenbeck),  474;    shoulder, 

476;    tendon  suture,  479;    nerve  suture,  479;    intravenous  saline  infusion, 

PAKT  X. 
Loweb  Extremity 482-549 

Thigh:  Gluteal  region,  482;  stretching  sciatic  nerve,  483;  anterior  femoral 
region,  485;  internal  saphenous  vein,  485;  femoral  artery,  486;  anterior 
crural  nerve,  489;     ligation  of  femoral  artery,   489;    popliteal  space,  491. 

Leg:    Anterior  tibial  artery,  492;    anterior  tibial  nerve,  494;    ligation 

of  anterior  tibial  artery,  494;  posterior  tibial  artery,  494;  posterior  tibial 
nerve,  496;    ligation  of  posterior  tibial  artery,  496;    tenotomy,  496;    multiple 

ligature  of  veins  of  leg,   497. Amputations,   Resections,   etc. :     Surgical 

anatomy  of  skeleton  of  foot,  498;  exarticulation  of  big  toe,  500;  exar- 
ticulation of  big  toe  with  removal  of  first  metatarsal,  500;  exarticulation 
of  little  toe,  500;  for  ingrowing  toe-nail,  501;  amputation  through  tarso- 
metatarsal articulation  (Lisfranc),  501;  amputation  through  medio-tarsal 
articulation  (Chopart),  504;  surgical  anatomy  of  ankle-joint,  505;  exar- 
ticulation of  foot  at  ankle-joint  (Syme),  506;  exarticulation  of  foot,  etc. 
(Pirogoff),  507;  amputation  of  leg,  510;  amputation  of  leg  with  lateral 
hooded  flaps,  510;  surgical  anatomy  of  knee-joint,  513;  exarticulation  of 
leg  at  knee-joint  (Stephen  Smith),  516;  transcondylar  amputation  (Carden), 
518;  amputation  of  knee  (Gritti-Stokes),  520;  amputation  of  thigh,  521; 
surgical  anatomy  of  hip-joint,  523;  exarticulation  of  thigh  at  hip  (Wyeth), 
526;    exarticulation  of  thigh  with  preliminary  ligation  of  common  femoral, 

529. Resections:    Ankle  (Langenbeck-Hueter),  529;    ankle  (Koenig),  533; 

ankle  (Lauenstein),  535;  ankle,  osteoplastic  (Mikulicz-Wladimirow),  536; 
knee-joint,  538;  hip-joint  (Langenbeck),  543;  osteotomy,  547;  suture  of 
patella,  548. 


LIST  OF  ILLUSTRATIONS. 


FIQ. 


PAGE 


1.  Division  of  Skin  by  Transfixion a 

2.  Esmarch  Bandage  and  Constrictor 6 

3.  Trendelenburg  Position   9 

4.  Square  Knot  12 

5.  Slip  Knot   12 

6.  Surgeon's  Knot  12 

7.  Intracuticular  Suture    14 

8.  Bone-drill    15 

9.  10.     Segment  of  Bowel— Lembert  Sutures 16 

11.  Cushing  Suture 17 

12.  Hartley  Chisel   26 

13.  Temporary  Resection  of  Skull 27 

14.  Base  of  Skull  from  Within 32 

15.  Section  through  Floor  of  Middle  Fossa 35 

16.  Side  of  Skull 41 

17.  '  Pterygo-maxillary  Region    61 

18.  Pterygo-maxillary  Region  (deep) 62 

19.  Incisions  for  Resection  of  Upper  Jaw 65 

20.  Resection  of  Upper  Jaw 67 

21.  Incisions  for  Resection  of  Casserian  Ganglion 78 

22.  Transverse  Section  of  Head  End  of  Embryo  Twelve  Days  Old 81 

23.  Sagittal  Section  of  Head  End  of  Embryo  Twelve  Days  Old 81 

24.  Face  of  Embryo,  Fifth  Week 83 

25.  Face  of  Embryo,  Fifth  Week 84 

26.  Embryo,  Fourth  Week,  Seen  from  Side 85 

27.  Embryo,  Eighth  Week,  Seen  from  Side 86 

28.  Face  of  Embryo  about  Eighth  Week 88 

29.  Diagram  of  Congenital  Facial  Clefts 90 

30.  Double  Complete  Harelip 92 

31.  Harelip  with  Advanced  Intermaxillary  Portion 93 

32.  Double  Cleft  Palate  with  Advanced  Intermaxillary  Portion 94 

33.  Oblique  Facial  Cleft 96 

34.  Incomplete  Oblique  Facial  Cleft 97 

35.  Transverse  Facial  Cleft 97 

36.  37.     Simple  Paring  for  Incomplete  Harelip 100 

38,  39.    Von  Graef e  Operation  for  Incomplete  Harelip 100 

40,  41,  42.    Nelaton  Operation  for  Incomplete  Harelip 101 

43,  44,  45.    Malgaigne  Operation  for  Incomplete  Harelip 101 

46,  47,  48.    Mirault  Operation  for  Incomplete  Harelip 102 

49.  Wellenschnitt  for  Complete  Harelip 103 

50,  51,  52.    Hagedorn  Operation  for  Single  Complete  Harelip 103 

53,  54,  55.    Double  Malgaigne  Operation  for  Double  Complete  Harelip 105 

56,  57,  58.    Hagedorn  Operation  for  Complete  Double  Harelip 105 

59.  Whitehead  Gag   108 

60.  Repair  of  Cleft  Palate Ill 

61.  Excision  of  Entire  Lower  Lip 112 

62.  Triangular  Defect  in  Lower  Lip  Closed 112 

63.  Dieff enbach- Jaesche  Operation  for  Restoring  Lower  Lip 113 

64.  65.    Bruns  Method  of  Restoring  Lower  Lip 114 

(Xi) 


xii  LIST  OF  ILLUSTRATIONS. 

FIG.  PAGE 

66,  67.    Langenbeck  Method  of  Restoring  Lower  Lip 114 

6S,  69.    Estlander  Method  of  Restoring  Lower  Lip 115 

70,  71.     Dieffenbach  Wellenschnitt  for  Restoration  of  Upper  Lip 116 

72,  73.     Bruns  Method  of  Restoring  Upper  Lip 116 

74.  Section  through  Neck 118 

75.  Side  of  Neck  to  Show  Triangles 124 

76.  Front  of  Neck 131 

77.  Tracheotomy  Tube   142 

78.  Trendelenburg  Tampon  Cannula 142 

79.  Incision  for  Removal  of  Lower  Jaw,  etc 154 

80.  Transverse  Section  through  Thorax 178 

81.  Outline  of  Heart,  etc 181 

82.  83,  84.     Outline  of  Pleura,   etc 190 

85.  Section  through  Seventh,  Eighth,  and  Ninth  Ribs 191 

86.  Amputation  of  Breast 198 

87.  Transverse  Section  of  Abdomen 211 

88.  Transverse  Section  of  Abdomen 211 

89.  Regions  of  Abdomen 213 

90.  Sagittal  Section  to  Show  Arrangement  of  Greater  and  Lesser  Omenta 223 

91.  Incisions  to  Reach  Abdominal  Viscera 225 

92.  Gastroplication    226 

93.  Cross  Section  of  Stomach  after  Gastroplication 227 

94.  Cross  Section  of  Stomach  after  Gastroplication 227 

95.  96.     Pyloroplasty    231 

97,  98.    Gastrostomy  (Ssabanajew-Franck)    234 

99,  100.     Gastrostomy  (Witzel)   236 

101.  Pylorectomy    238 

102.  Pylorectomy    (Billroth)    240 

103.  Pylorectomy    (.Billroth)    241 

104.  Pylorectomy  (Eocher)    243 

105.  Gastrectomy    , 246 

106.  Intestine  Compressor  255 

107.  Enterectomy    256 

108.  End-to-End   Anastomosis    , 258 

109.  110,  111.    End-to-End  Anastomosis   (Mounsell) 260 

112.  End-to-End  Anastomosis  (Murphy  Button) 263 

113.  Murphy  Button   263 

114.  115,  116.    Laplace  Anastomosis  Forceps 265 

117,  118,  119.     O'Hara  Anastomosis  Forceps 267 

120.  Lateral  Anastomosis   269 

121.  Cross  Section  of  the  Apposed  Coils  of  Gut  (Lateral  Anastomosis) 270 

122.  Gastro-enterostomy  ("Vicious  Circle") 273 

123.  Posterior   Gastro-enterostomy    277 

124.  Gastro-enterostomy  (Jaboulay-Brauri)   278 

125.  Lateral  Anastomosis  (Murphy  Button) 279 

126.  Gastro-enterostomy  (McGraw  Rubber  Suture) 282 

127.  Colostomy   291 

128.  Colostomy   (Maydl)    293 

129.  Colostomy   294 

130.  Colostomy  (Maydl)    294 

131.  Appendix   303 

132.  Appendicectomy    303 

133.  Appendicectomy    304 

134.  Bile-ducts,   etc 313 

135.  Gall-bladder    319 

136.  Cholecystostomy   320 

137.  Keen    Bone   Forceps 333 

138.  Lumbar  Puncture    336 

139.  Complete  FistuJa  in  Ano 343 


LIST  OF  ILLUSTRATIONS.  xiii 

FIG.  PAGE 

140.  Blind  Internal   Fistula 343 

141.  Blind  External  Fistula 343 

142.  Hemorrhoids   345 

143.  Incision  for  Resection  of  Rectum  (Kraske) 354 

144.  Ilium  and  Sacrum  (Kraske) 355 

145.  Resection  of  Rectum   (Kraske) 357 

146.  Resection  ofRectum   (Kraske) 357 

147.  Resection  of  Rectum   (Kraske) 360 

148.  Inguinal  and  Femoral  Regions 364 

149.  Inguinal  Canal  366 

150.  Descent  of  Testis 369 

151.  Inguinal   Region    370 

152.  Inguinal  Region,  Congenital  Hernia 370 

153.  Inguinal  Region,  Acquired  Hernia 370 

154.  Superficial  Femoral  Region 372 

155.  Superficial  Femoral  Region — Femoral  Sheath 372 

156.  Pelvis  and  Ligaments  of  Ilio-pubic  (or  Femoral  ?)  Region 374 

157.  Femoral  Space  374 

158.  Deep  Femoral  Region 375 

159.  Inguinal  and  Femoral  Regions  from  Within  Abdomen 376 

160.  Irregular  Origin  of  Obturator  Artery 381 

161.  Irregular  Origin  of  Obturator  Artery 382 

162.  Operation  for  Inguinal  Hernia 384 

163.  Bassini  Operation  for  Inguinal  Hernia 386 

164.  Bassini   Operation    386 

165.  Halsted's  Operation  for  Hernia 391 

166.  Operation  for  Femoral  Hernia 392 

167.  Spermatic  Cord  394 

168.  Cross  Section  of  Spermatic  Cord 394 

169.  Exposure   of   Cord 394 

170.  Varicocele     396 

171.  Hydrocele,   Tapping   398 

172.  Volkmann  Operation  for  Hydrocele 398 

173.  Hydrocele,  Retroversion  of  Tunica  Vaginalis 400 

174.  Castration     401 

175.  Incision  to  Expose  Kidney 405 

176.  Nephropexy  (Edebohls)  409 

177.  Relations  of  Peritoneum  to  Bladder 415 

178.  Dorsal  Section   (Roser) 420 

179.  Circumcision   421 

180.  181.    Amputation  of  Penis 423 

182.  Perineum  and  Ischio-rectal  Region 426 

183.  Axillary  Region    438 

184.  Section  through  Middle  of  Right  Arm 441 

185.  Section  through  Middle  of  Right  Forearm 444 

186.  Right  Arm,  Incisions,  etc 448 

187.  Exarticulation  of  Finger 451 

188.  Exarticulation  of  Finger 452 

189.  Palmar  Aspect  of  Right  Hand 454 

190.  Dorsal  Aspect  of  Right  Hand 454 

191.  Stump  after  Exarticulation  of  Hand 455 

192.  Right  Arm,  Anterior  Aspect 462 

193.  Right  Shoulder,  Anterior  View 466 

194.  Right  Shoulder,  Posterior  View 468 

195.  Left  Shoulder,  Side  View 469 

196.  Left  Arm,   Posterior  View 471 

197.  Resection  of  Wrist-joint 472 

198.  Tendon  Suture 479 

199.  Superficial  Vein  Exposed  for  Saline  Infusion 480 


xiv  LIST  OF  ILLUSTRATIONS. 

FIG.  PAGE 

200.  Stretching  Sciatic  Nerve 484 

201.  Section  through  the  Middle  of  the  Left  Thigh 487 

202.  Ligation  of  Femoral  Artery 490 

203.  Section  through  the  Middle  of  the  Left  Leg 493 

204.  Right  Foot   498 

205.  Operations  for  Ingrowing  Toe-nail 501 

206.  Right  Foot,  Inner  Side 503 

207.  Right  Foot,   Outer  Side 503 

208.  Right  Foot,  Inner  Side  (Pirogoff 's  Amputation) 508 

209.  Right  Foot,  Inner  Side  (Giinther's  Modification ) 508 

210.  Right  Foot,  Inner  Side  (le  Fort's  Modification) 508 

211.  Amputation  of  Leg 511 

212.  Right  Leg,  Outer  Side 517 

213.  Right  Leg  (Carden's  Amputation) 519 

214.  Stump  after  Carden's  Amputation 519 

215.  Gritti-Stokes  Amputation   521 

216.  Exarticulation  at  Hip-joint 527 

217.  Right  Foot,  Outer  Side  (Langenbeck-Hueter) 530 

218.  Right  Foot,  Inner  Side  (Langenbeck-Hueter) 530 

219.  Incisions  for  Resection  of  Ankle  (Koenig)  and  for  Amputation  of  Big  Toe  with 

Removal  of  the  First  Metatarsal 533 

220.  Resection  of  Ankle-joint  (Lauenstein's  Incision) 536 

221.  Incision  for  Mikulicz-Wladimirow  Osteoplastic  Resection  of  the  Ankle-joint 537 

222.  Right  Leg,   Inner  Side 539 

223.  Resection  of  Knee-joint 541 

224.  Resection  of  Hip  (Langenbeck's  Incision) 544 

225.  Resection  of  Hip  (Anthony  White's  Incision) 545 

226.  Osteotomy   (Macewen)    547 

227.  Wiring  Patella  for  Fracture 549 


PART    I. 

GENERAL    CONSIDERATIONS 


ANAESTHESIA. 

General  Anaesthesia.  —  Of  the  general  anaesthetics,  ether  and 
chloroform  are  the  ones  most  commonly  employed.  Ether  is  used 
more  generally  than  chloroform,  especially  in  this  part  of  the  United 
States.  With  ether,  the  stage  of  excitement  and  struggling  that 
precedes  the  stage  of  anaesthesia  is  more  prolonged  and  more  pro- 
nounced than  with  chloroform;  still,  this  objection  may  be  partially 
eliminated  by  administering  nitrous  oxide  or  chloroform  until  the 
period  of  excitement  has  been  passed.  The  preliminary  use  of 
nitrous  oxide  is  much  in  vogue  at  present. 

Ether  stimulates  the  heart  and  increases  the  arterial  tension. 
It  has  a  marked  congestive  influence  upon  the  kidneys,  and  acts  as 
an  irritant  to  the  respiratory  tract. 

The  first  stage  of  chloroform  narcosis  is  shorter  than  is  that 
of  ether  and  is  not  accompanied  by  as  much  excitement  and  strug- 
gling. Chloroform  does  not  increase  the  arterial  tension  and  does 
not  congest  the  kidneys,  but  it  has  a  tendency  to  interfere  with  the 
heart-action,  especially  if  the  heart-muscle  is  diseased  and  in  con- 
ditions accompanied  by  chronic  anaemia.  Therefore,  if  it  become  a 
matter  of  choice,  one  should  elect  ether  if  the  heart-action  is  un- 
satisfactory or  if  the  patient  is  markedly  anaemic,  and  chloroform  if 
the  urine  shows  defective  kidneys  or  if  there  is  a  tendency  to  cere- 
bral apoplexy  or  pulmonary  disease  and  in  cases  of  empyema.  Chlo- 
roform is  also  preferable  to  ether  in  young  children  and  in  very  old 
people.  Alcoholics,  as  a  rule,  take  chloroform  much  more  satisfac- 
torily than  ether. 

In  operations  about  the  mouth  where  the  mask  can  only  be 
applied  during  intervals,  and  for  administration  through  a  trache- 
otomy tube,  chloroform  is  the  preferable  anaesthetic. 

Incomplete  General  Anaesthesia. — This  plan  consists  in  admin- 
istering a  liberal  dose  of  morphin  hypodermically,  shortly  before 
commencing  the  operation,  and  then  giving  the  chloroform  only  up 

(1) 


2  GENERAL  CONSIDERATIONS. 

to  the  point  of  deadening  the  sensation  without  nullifying  the  re- 
flexes. In  this  way  the  pain  is  made  endurable  and  at  the  same 
time,  the  reflexes  being  still  active,  the  patient  is  able  to  cough,  clear 
the  throat,  and  expectorate.  This  plan  may  be  practiced  with  satis- 
faction in  operations  about  the  upper  and  lower  jaw,  nasal  passages, 
larynx,  etc.,  where  there  is  danger  of  blood  entering  the  respiratory 
canal  and  asphyxiating  the  patient  if  not  coughed  out. 

Local  Anaesthesia. — The  skin  may  be  anaesthetized  sufficiently 
for  simple  incision  or  puncture  by  freezing,  either  by  the  application 
of  ice,  chopped  and  mixed  with  salt,  in  a  bag,  or  by  the  ethyl- 
chloride  spray. 

Ethyl  chloride  is  a  very  volatile  substance,  boiling  at  the  body- 
temperature.  It  is  supplied  in  glass  cylinders  with  a  removable 
brass  cap.  If  the  cylinder  is  held  in  the  hand  for  a  few  moments 
sufficient  heat  is  imparted  to  volatilize  the  fluid  in  the  cylinder, 
which  then  escapes  in  the  form  of  a  fine  spray.  The  spray  is 
directed  against  the  part  to  be  anaesthetized  for  a  few  minutes. 

For  operations  that  require  a  certain  amount  of  dissection  cocain 
in  a  2-per-cent.  solution,  introduced  into  the  skin,  hypodermically, 
is  more  satisfactory.  The  cocain  is  still  more  effective  if  it  can  be 
confined  to  the  part  that  is  to  be  operated  upon  by  constricting  it 
with  a  rubber  elastic  ligature;  for  example,  in  operations  upon  the 
fingers  and  toes  and  for  circumcision,  etc.,  by  placing  an  elastic 
ligature  about  the  root  of  the  part.  The  solution  should  be  thrown 
into  the  deeper  layer  of  the  skin  proper  so  as  to  raise  welts,  and. 
not  into  the  loose  tissue  underneath  the  skin. 

The  solution  is  introduced,  a  few  drops  at  a  time,  through 
several  punctures  along  the  line  of  the  proposed  incision. 

After  the  first  puncture  and  injection  have  been  made,  the 
needle  should  be  introduced  each  succeeding  time  through  the  skin 
that  has  already  been  anaesthetized;  ordinarily  from  20  to  30  minims 
of  a  2-per-cent.  solution,  according  to  the  age,  etc.,  of  the  patient,, 
may  be  introduced  during  the  course  of  a  single  operation. 

Occasionally  disagreeable  symptoms  of  cardiac  disturbances  due 
to  the  action  of  the  cocain  present  themselves,  especially  if  it  has 
been  introduced  into  a  part  where  the  circulation  cannot  be  inter- 
rupted with  a  constricting  ligature.  Mucous  surfaces  may  be  anaes- 
thetized by  applying  a  wad  of  cotton  saturated  with  the  cocain 
solution  direct  to  the  part  for  several  minutes. 

Eucain  is  used  as  a  substitute  for  cocain;   it  is  said  to  have  no 


ANESTHESIA.  3 

depressing  influence  upon  the  heart.     From  20  to  40  minims  of  a 
2-per-cent.  solution  may  be  used. 

Schleich  Infiltration  Method. — The  solution  used  contains 
cocain  and  morphin.  It  is  thrown  into  the  skin  with  a  hypodermic, 
as  described  "above  for  cocain,  along  the  course  of  the  intended 
incision.  The  solutions  vary  in  strength  according  to  the  amount 
of  cocain  that  they  contain,  and  are  known  as  Nos.  1,  2,  and  3. 

Solution  No.  1. 

Cocain  muriate       gm.      0.2  gr.  iij. 

Morphin  muriate gm.       0.025  gr.  f . 

Sodium  chloride gm.      0.2  gr.  iij. 

Sterile  water       c.c.  100.0  Siiif- 

This  is  the  strongest  solution.  A  quantity  up  to  6  drams  may 
be  used. 

Solution  No.  2. 

Cocain  muriate       gm.      0.1  gr.  iss. 

Morphin  muriate gm.      0.025  gr.  f. 

Sodium  chloride gm.      0.2  gr.  iij. 

Sterile  water c.c.   100.0  giiif . 

This  is  the  solution  that  is  commonly  used,  and  of  this  a  quan- 
tity up  to  3  ounces  may  be  injected. 

Solution  No.  3. 

Cocain  muriate gm. 

Morphin  muriate gm. 

Sodium  chloride gm. 

Sterile  water c.c. 

No.  3  is  the  weakest  solution,  containing  only  one-tenth  as 
much  cocain  as  No.  2. 

One  may  use  a  pint  of  this  solution. 

Analgesia  by  Subarachnoid  Injection  of  Cocain,  etc. — A  solu- 
tion of  cocain,  eucain,  etc.,  may  be  thrown  into  the  subarachnoid 
space  with  a  hypodermic  syringe.  This  method  of  inducing  anal- 
gesia was  introduced  by  Bier  and  has  been  recently  practiced  by 
numerous  surgeons  with  varying  degrees  of  satisfaction,  some  dis- 
carding it  after  a  few  trials  and  others  advocating  its  usefulness. 
No  doubt  it  will  prove  of  value  in  certain  cases.  The  method  of  in- 
troducing the  fluid  is  described  elsewhere  (see  "Lumbar  Puncture"). 

A  1-  or  2-per-cent.  solution  of  cocain,  eucain,  or  tropacocam 
may  be  used. 


0.01 

gr-  h 

0.025 

gr.  h 

0.2 

gr.  ii] 

100.0 

giiif. 

4  GENERAL  CONSIDERATIONS. 

If  the  cocain  solution  is  sterilized  by  boiling,  the  potency  of 
the  drug  is  very  much  impaired.  We  may  thus  account  for  some 
of  the  instances  where  the  method  has  failed  to  give  satisfaction. 
If  cocain,  for  example,  is  used,  1/2  grain  or  less  of  the  crystals  of 
hydrochlorate  of  cocain  is  placed  in  a  sterile  glass  vessel  and  1  or 
2  drams  of  ether  poured  in;  this  is  stirred  with  a  sterile  glass  rod 
until  the  ether  evaporates,  when  the  residue  is  dissolved  with  steril- 
ized distilled  water  (Bainbridge).  The  solution  is  then  ready  for 
injection. 

According  to  the  method  of  Dudley,  the  cocain  may  be  steril- 
ized by  adding  a  few  drops  of  chloroform  to  the  crystals  of  the  drug. 
After  the  chloroform  evaporates  the  residue  is  dissolved  in  sterile 
water. 

Three  to  seven  minutes  usually  elapse  before  the  analgesia 
reaches  the  level  of  the  diaphragm.  The  lower  limbs  and  the  lower 
part  of  the  trunk  first  show  the  analgesic  effect  of  the  drug,  and 
this  gradually  extends  to  the  chest  and  upper  extremities. 

The  analgesic  effect  lasts  from  fifteen  minutes  to  several  hours. 

The  method  may  be  applicable  in  those  cases  where  extreme 
weakness  or  cardiac  or  renal  disease  renders  the  use  of  chloroform 
or  ether  especially  dangerous. 

DIVISION  OF  THE  TISSUES. 

Division  of  the  Soft  Parts.  Bloody  Division  of  the  Soft 
Parts. — The  division  of  the  integument  may  be  accomplished  with 
the  knife  or  scissors,  either  by  direct  incision  or  by  transfixion 
(Fig.  1).  The  deeper  soft  parts  may  be  divided  with  cutting 
instruments  or  by  tearing  with  the  fingers  or  blunt  instruments, 
the  handle  of  the  scalpel,  thumb  forceps,  etc.  This  plan  of  blunt 
dissection  is  especially  serviceable  in  enucleating  encapsulated  tu- 
mors or  lymphatic  nodes  and  in  separating  between  different  layers 
of  tissue  along  the  normal  connective-tissue  planes. 

The  contents  of  hollow  viscera,  serous  spaces,  and  cystic  tumors 
may  be  evacuated  or  withdrawn  in  part  for  the  purpose  of  diagnosis 
by  means  of  the  trocar  and  cannula  or  some  form  of  aspirating 
apparatus.  Substances  may  also  be  introduced  into  the  body  through 
cannula?  or  with  some  form  of  syringe. 

Bloodless  Division  of  the  Soft  Parts. — This  may  be  accom- 
plished with  the  thermocautery,  galvanocautery,  elastic  ligature, 
ecraseur,  or  wire  snare  and  by  the  action  of  corroding  chemicals. 


HEMORRHAGE.  5 

Division  of  Bone. — Bones  may  be  divided  through  an  incision 
in  the  soft  parts  with  the  chisel  and  mallet,  bone  forceps,  or  with 
some  form  of  saw, — circular,  chain,  or  wire,  or  with  the  flat  saw; 
with  the  drill,  dental  burr,  or  bone  scoop. 

The  bongs  are  covered  with  an  adherent  vascular  membrane, 
the  periosteum,  which  should  be  incised  with  the  knife  and  sepa- 
rated from  the  bone  with  the  elevator  before  applying  the  cutting 
instruments  to  the  bone. 

The  bone  may  be  divided  without  an  incision  in  the  soft  parts 
— for  the  purpose  of  correcting  deformities,  etc. — either  by  manual 
force  or  by  the  use  of  an  instrument  known  as  the  osteoclast.  The 
osteoclast  consists  of  a  solid  metal  bar  with  two  sliding  bracelets 


Fig.  1. — Division  of  the  Skin  by  Transfixion. 

one  on  either  end  and  between  these  a  brace  by  which  the  breaking 
force  is  applied  and  which  may  be  raised  or  lowered  by  means  of  a 
screw. 

HEMORRHAGE. 

During  the  course  of  an  operation  the  hemorrhage  must  be 
controlled  in  order  to  minimize  the  loss  to  the  patient  and  to  keep 
the  field  clear  for  proper  work. 

Hemorrhage  may  be  described  as  capillary,  venous,  and  arterial. 

Capillary  hemorrhage  is  characterized  by  a  general  oozing. 

Venous  hemorrhage  is  characterized  by  a  steady  welling  of 
blood  into  the  wound,  often  filling  it  so  as  to  obscure  the  bleeding 
point.  Venous  blood  is  rather  darker  in  color  than  arterial  blood. 
If  a  large  vein  is  divided  close  to  the  trunk, — i.e.,  in  the  neck  or 
axilla, — or  if  one  of  the  intracranial  dura  mater  sinuses  is  opened, 
the  blood  may  escape  in  a  remittent  stream,  synchronous  with  the 
respiratory  movements,  diminishing  or  ceasing  during  inspiration 
and  increasing  during  expiration.     During  inspiration,  under  these 


6  GENERAL  CONSIDERATIONS. 

circumstances,  air  may  be  sucked  into  the  veins,  but,  if  limited  in 
quantity,  this  is  said  to  do  no  harm;  nevertheless  it  should  be 
guarded  against. 

Arterial  hemorrhage  is  characterized  by  the  brighter  color  of 
the  blood  and  by  the  fact  that  it  escapes  in  a  distinct  remittent 
jet  of  considerable,  though  varying,  force.  The  jet  is  synchronous 
with  the  heart's  action,  increasing  during  ventricular  systole  and 
diminishing  during  ventricular  diastole. 

Means  to  Arrest  Hemorrhage.  The  Natural  Arrest  of 
Hemorrhage  is  effected  by  the  clotting  of  the  blood.  If  the  divided 
vessels  are  not  too  large  and  the  blood-pressure  not  too  great, 
nature  will  thus  be  able  to  bring  about  a  cessation  of  the  hemor- 
rhage. Nature  is  assisted  in  her  efforts  to  control  hemorrhage  from 
a  severed  artery  by  the  fact  that  when  an  artery  is  divided  its 
orifice  contracts,  thus  diminishing  the  size  of  the  opening  through 


Fig.  2.— Esmarch  Bandage  and  Constrictor.    The  constrictor  is  provided 
with  a  chain  and  hook. 

which  the  blood  escapes,  and  further  by  the  fact  that  the  inner 
elastic  coat  of  the  vessel,  the  intima,  retracts,  coiling  up  within  the 
artery,  thus  blocking  the  lumen  of  the  vessel  and  offering  a  con- 
siderable impediment  to  the  flow. 

The  natural  arrest  of  hemorrhage  from  a  severed  vein  is  facili- 
tated by  the  low  blood-pressure  within  the  vessel  and  by  the  col- 
lapsibility  of  its  thin,  flaccid  wall. 

Artificial  Arrest  of  Hemorrhage. — Artificial  measures  are 
resorted  to,  as  a  rule,  to  control  hemorrhage.  These  may  be  classi- 
fied as  indirect  means,  acting  outside  at  a  distance  from  the  wound, 
and  direct  means,  acting  locally  within  the  wound. 

Indirect  Means.  The  Elastic  Bandage  and  Constrictor 
(Esmarch). — Operations  upon  the  extremities  may  be  rendered 
practically  bloodless  by  the  use  of  the  Esmarch  bandage  and  con- 
strictor. 


HEMORRHAGE.  7 

The  extremity  being  elevated,  a  rubber  bandage  about  three 
inches  broad  is  applied  about  the  limb,  each  turn  being  drawn  pretty 
tight.  The  bandage  is  applied  spirally  about  the  limb,  commencing 
below  and  working  upward  toward  the  trunk,  each  turn  somewhat 
overlapping  its  predecessor;  in  this  way  the  blood  is  forced  out  of 
the  limb.  B"aving  reached  a  point  above  the  site  of  the  proposed 
operation,  a  rubber  band  or  thick  elastic  tube,  the  constrictor,  is 
passed  around  the  limb  several  times  and  then  made  fast.  The 
rubber  spiral  bandage  may  then  be  removed. 

In  most  cases  the  application  of  the  rubber  spiral  bandage  may 
be  dispensed  with,  it  being  sufficient  to  elevate  the  limb  to  a  per- 
pendicular position  for  a  few  minutes,  at  the  same  time  massaging 
or  stripping  it  from  the  periphery  toward  the  trunk,  in  order  to 
force  the  bulk  of  the  blood  out  of  it.  "While  the  limb  is  thus 
elevated,  the  rubber  constrictor  bandage  or  tube  is  applied  about 
the  upper  part  of  the  limb. 

In  cases  of  tuberculous  disease,  malignant  disease,  and  sepsis 
one  should  certainly  omit  stripping  the  limb  or  applying  the  rubber 
spiral  bandage  on  account  of  the  likelihood  of  forcing  infectious 
elements  onward  into  the  healthy  tissues.  Under  these  circum- 
stances one  should  be  content  with  elevation  of  the  limb  for  a  few 
minutes  before  applying  the  constrictor. 

The  rubber  constrictor  that  is  placed  about  the  limb  may  be 
secured  with  a  band  of  gauze  which  is  placed  underneath  the  con- 
strictor so  that  after  the  first  loop  of  an  ordinary  knot  has  been 
taken  in  the  constrictor  the  gauze  bandage  may  be  tied  over  this 
to  secure  it  and  prevent  it  from  slipping;  the  second  and  final  loop 
is  then  taken  in  the  rubber  constrictor.  The  constrictor  shown  in 
the  illustration  is  provided  with  a  chain  and  hook. 

The  constrictor  should  be  applied  sufficiently  tight  to  shut  off 
the  arterial  current,  but  not  tight  enough  to  bruise  the  nerve-trunks 
against  the  underlying  bone.  The  constrictor  may  be  left  on  for 
two  or  three  hours  without  any  untoward  results. 

For  operations  upon  the  lower  extremity,  except  at  the  hip-joint, 
the  constrictor  is  placed  about  the  thigh,  just  above  the  knee-joint 
or  higher  up,  nearer  the  hip-joint.  For  disarticulation  at  the  hip- 
joint  the  constrictor  is  placed  about  the  limb  as  high  up,  near  the 
trunk,  as  possible,  and  it  is  then  prevented  from  slipping  down  by 
steel  pins,  or  skewers,  which  are  passed  through  the  soft  parts 
(Wyeth). 


S  GENERAL  CONSIDERATIONS. 

For  operations  upon  the  upper  extremity,  except  at  the  shoulder- 
joint,  the  ligature  is  placed  about  the  arm,  just  above  the  elbow- 
joint  or  higher  up  nearer  the  shoulder- joint.  For  disarticulation 
at  the  shoulder-joint  the  constrictor  is  applied  as  high  up  as  pos- 
sible; it  may  be  passed  through  the  axilla  and  over  the  shoulder 
and  prevented  from  slipping  by  a  steel  pin,  or  skewer,  that  is  thrust 
through  the  soft  parts,  transfixing  the  upper  part  of  the  deltoid 
muscle  mass. 

The  main  arterial  and  venous  trunks,  if  they  have  been  divided 
during  the  course  of  the  operation,  may  be  secured  and  ligated  before 
the  constrictor  is  removed.  Any  additional  bleeding  branches  may 
be  secured  and  ligated  after  the  constrictor  has  been  removed. 

By  Digital  Compression  of  the  Main  Arterial  Trunk  at  a  Distance 
from  the  Site  of  the  Operation. — During  amputation  of  the  thigh 
the  common  femoral  artery,  as  it  emerges  from  under  Poupart's 
ligament,  may  be  compressed  against  the  underlying  pubic  bone. 

During  amputation  of  the  forearm  or  disarticulation  at  the 
elbow-joint  the  brachial  may  be  compressed  against  the  humerus, 
and  during  amputation  through  the  upper  arm  or  at  the  shoulder- 
joint  the  hemorrhage  may  be  controlled  by  digital  compression  of 
the  subclavian  artery  against  the  first  rib.  This  plan  is  rather 
untrustworthy. 

Preliminary  Ligation  in  Continuity. — This  is  a  very  satisfactory 
method  of  controlling  hemorrhage  in  certain  bloody  operations.  For 
example,  in  disarticulation  at  the  hip-joint  preliminary  ligation  of 
the  common  femoral  may  be  practiced,  the  vein  being  tied  at  the 
same  time  through  the  same  incision.  In  amputation  of  the  tongue 
one  or  both  Unguals  may  be  ligated  as  a  preliminary  step  to  the 
main  procedure.  In  extirpation  of  the  lower  jaw,  etc.,  preliminary 
ligation  of  the  external  carotid  may  be  practiced  with  great  advan- 
tage. 

Position. — Position  of  the  part  has  much  to  do  with  the  severity 
of  the  hemorrhage  during  an  operation.  Elevation  of  the  part  is 
often  sufficient,  of  itself,  to  check  capillary  and  venous  hemorrhage. 
The  volume  of  arterial  blood  sent  to  the  part  is  diminished  and  the 
return-flow  through  the  veins  is  facilitated.  These  factors,  together, 
serve  to  markedly  diminish  the  pressure  in  all  the  vessels  of  the 
elevated  part.  This  is  especially  true  of  the  limbs,  but  also  of  the 
pelvis  and  the  head.  With  the  pelvis  raised  as  in  the  Trendelenburg 
position,  the  hemorrhage  during  the  course  of  operations  upon  the 


HEMORRHAGE.  9 

pelvic  organs  is  much  diminished.  During  operations  upon  the  head 
and  face,  with  the  patient  in  the  semi-erect  position,  the  hemorrhage, 
especially  the  venous,  will  be  found  to  be  very  much  less  than  it 
would  be  with  the  patient  in  the  Kose  position,  with  the  head  hanging 
low  over  the  end  of  the  table. 

Direct  Means  of  Controlling  Hemorrhage  are  applied 
within  the  wound  itself,  and  these  may  be  divided  into  three  groups: 
Agents  that  act  locally  through  the  nervous  system;  chemical  agents 
that  act  directly  upon  the  escaping  blood,  causing  it  to  coagulate; 
and  mechanical  agents. 

Agents  that  Act  Locally  through  the  Nervous  System. — Application 
of  heat  or  cold,  usually  in  the  form  of  water,  hot  or  cold,  or  ice, 


Trendelenburg  Position. 


tends  to  diminish  and  check  hemorrhage.  If  hot  water  is  used  it 
should  be  as  hot  as  the  hand  can  bear,  about  120°  F.;  if  cold,  it  should 
be  quite  cold. 

Heat  and  cold  both  act  by  causing  the  small  arterioles  to  con- 
tract and  diminish  in  size.  Heat  causes  albumin  to  coagulate  so  that, 
when  heat  is  applied  to  a  wound,  the  wound  surface  becomes  glazed 
with  a  thin,  albuminous  film,  and  in  this  way  heat  possesses  an 
additional  potency  in  checking  oozing.  Heat  is  a  more  effective 
agent  in  controlling  hemorrhage  than  cold,  since  the  latter  acts  only 
by  causing  a  diminution  in  caliber  of  the  small  arteries. 

Heat  in  the  form  of  a  hot  saline  irrigation  is  a  very  satisfactory 
agent  to  check  oozing  from  capillaries  and  small  arteries  and  veins. 


10  GENERAL  CONSIDERATIONS. 

Chemical  Agents.  Styptics. — These  agents  tend  to  check  hem- 
orrhage by  acting  directly  upon  the  escaping  blood,  causing  it  to 
coagulate,  and  thus  seal  the  mouths  of  the  severed  vessels.  They 
are  but  little  used  except  in  operations  upon  the  nose,  etc.,  and  are 
of  service  only  to  control  capillary  hemorrhage  and  oozing  from 
small  veins  and  arteries.  The  common  styptics  are  the  persulphate 
of  iron,  tincture  of  the  chloride  of  iron,  powdered  alum,  tannic  acid, 
extract  of  suprarenal  capsule,  etc. 

The  styptic  cotton  is  ordinary  absorbent  cotton  impregnated 
with  one  of  these  agents. 

Mechanical  Means.  Digital  Compression.  —  With  the  finger 
in  the  wound  hemorrhage  may  be  controlled  by  pressure  exerted 
directly  upon  a  severed  vessel,  thus  closing  it  until  it  can  be  secured 
with  an  artery  forceps.  In  operations  upon  the  neck,  for  example, 
a  large  vessel  may  be  divided  and  then  so  obscured  by  the  great 
volume  of  escaping  blood  that  it  cannot  be  located  and  secured  with 
the  artery  forceps.  With  the  finger  thrust  into  the  wound  the  hem- 
orrhage may  be  checked  temporarily  by  compressing  the  injured 
vessel  until  the  wound  can  be  cleared  of  blood  and  the  vessel  located 
and  grasped  with  an  artery  clamp.  This  is  especially  true  of  large 
veins;  when  cut,  the  blood  may  well  into  the  wound  in  such  volume 
that  one  is  unable  to  locate  the  divided  vessel. 

Digital  compression  may  be  applied  to  the  main  vessels  in  the 
wound  before  they  are  divided  in  order  to  minimize  the  loss  of 
blood.  For  example,  in  exarticulating  at  the  shoulder-joint,  after 
the  incisions  have  been  made,  but  before  the  brachial  artery  and 
adjoining  vessels  have  been  cut,  the  assistant  grasps  the  mass  of 
soft  parts  which  includes  the  main  vascular  trunks  and  compresses 
these  between  the  thumb  and  fingers  until  after  the  limb  has  been 
amputated  and  the  vessels  secured  by  the  operator. 

Tamponade. — This  is  really  one  way  of  applying  the  principle 
of  compression.  This  method  is  especially  serviceable  in  controlling 
oozing  and  bleeding  from  veins.  For  example,  hemorrhage  from  an 
injured  intracranial  sinus  may  be  readily  controlled  by  packing  a 
strand  of  gauze  into  the  wound  between  the  sinus  and  the  skull. 

If  a  wound  is  tamponed  and  a  good  snug  dressing  applied  so  as 
to  exert  a  considerable  degree  of  firm  compression,  this  will  usually 
suffice  to  check  all  oozing  from  capillaries  and  small  veins. 

Bleeding  from  the  nutrient  artery  of  a  bone  may  be  checked 
by  plugging  the  orifice  of  the  nutrient  canal  with  a  piece  of  catgut 


HEMORRHAGE.  11 

or  a  wooden  peg.  Oozing  from  the  end  of  a  long  bone,  from  the 
edges  of  the  bones  of  the  skull  in  craniectomy,  etc.,  is  readily  con- 
trolled by  a  few  minutes'  firm  compression  with  a  hot  gauze  pad. 

Suture  of  the  Wound  controls  hemorrhage  from  capillaries  and 
small  veins  by  bringing  the  contiguous  surfaces  into  apposition,  and 
is  simply  one  method  of  applying  the  principle  of  compression. 

Forcipressure  consists  in  crushing  the  coats  of  the  severed  ves- 
sels with  haemostatic  forceps.  It  is  a  well-known  fact  that  even 
large  arteries  when  crushed  or  torn  do  not  bleed,  and  it  is  upon  this 
same  principle  that  forcipressure  is  applied  to  control  hemorrhage. 

The  bleeding  artery  or  vein  is  seized  with  the  forceps,  which  is 
then  closed  down  upon  the  vessel  with  much  force,  in  this  way 
crushing  the  coats  of  the  vessel,  especially  the  inner  coat  and  so 
effectually  controlling  the  hemorrhage.  If  the  vessels  are  small  the 
iorceps  may  be  removed  after  a  few  minutes,  when  it  will  be  found 
that  the  hemorrhage  has  ceased.  Forcipressure  is  a  very  satisfactory 
method  of  dealing  with  larger  vessels  when  situated  deep  in  a  small 
wound  where  they  are  not  readily  accessible  for  ligation.  Under 
these  circumstances,  however,  it  is  wise  to  allow  the  forceps  to  re- 
main in  place  for  twenty-four  to  forty-eight  hours,  including  them 
in  the  dressing,  since  the  hemorrhage  might  recur  if  they  were 
removed  earlier.  By  allowing  the  forceps  to  remain  one  gives  the 
blood  a  chance  to  form  a  good  firm  clot  to  occlude  the  vessel.   ' 

The  angiotribe,  a  bulky  crushing  instrument,  is  applied  upon 
this  principle.  It  is  provided  with  a  screw  which  enables  one  to 
•apply  great  pressure  to  the  parts  within  the  grasp  of  its  blades. 
This  instrument  has  been  used  for  crushing  the  broad  ligament  in 
vaginal  hysterectomy,  but  has  not,  as  yet,  won  for  itself  a  place  in 
popular  favor. 

Torsion. — This  method  of  occluding  a  bleeding  vessel  consists 
in  seizing  the  end  and  twisting  it  until  the  inner  coat  of  the  vessel 
is  ruptured  and  the  end  of  the  vessel,  in  the  grasp  of  the  forceps, 
is  twisted  free.  This  measure  may  be  applied  to  small  arteries  and 
veins  as  an  adjunct  to  forcipressure.  Torsion  may  be  more  effect- 
ually applied  by  grasping  the  free  end  of  the  vessel  with  one  forceps 
and  the  vessel  itself  a  short  distance  beyond,  transversely,  with  a 
second  forceps.  While  the  vessel  is  steadied  with  the  forceps  that 
grasps  it  transversely,  it  is  twisted  repeatedly  upon  itself  with  the 
forceps  that  grasps  its  extremity. 

Ligature. — The  most  commonly  employed  and  safest  means  of 


12  GENERAL  CONSIDERATIONS. 

securing  severed  arteries  and  veins  especially  if  of  large  caliber.  In 
the  day  of  the  non-absorbable,  non-aseptic  ligature  many  plans  were 
devised  to  obviate  the  use  of  the  ligature,  since  it  had  to  be  cast 
off  before  the  wound  could  heal  and  thus  precluded  the  possibility 
of  union  by  first  intention,  and  because,  as  the  ligature  separated 
and  came  away,  it  wTas  often  accompanied  by  a  dangerous  secondary 
hemorrhage. 

With  the  aseptic,  absorbable  ligature,  an  ideal  method  of  con- 
trolling hemorrhage  in  the  wound  was  instituted.  The  aseptic,  ab- 
sorbable ligature  permits  the  immediate  closure  of  the  wound  and 
does  not  in  any  way  interfere  with  the  healing  process.     Some  sur- 


Fig.  4.— Square  Knot.  Fig.  5.— Slip-knot. 


Fig.  6.— Surgeons'  Knot.    The  first  loop  is  made  double  to  prevent  slipping 
while  taking  the  second  loop. 

geons  still  use  silk  for  ligature.  Although  silk  may  be  rendered 
absolutely  aseptic,  it  has  the  disadvantage  of  not  being  absorbable, 
and  may  therefore  occasionally  act  as  a  foreign  body,  keeping  the 
wound  open  until  it  separates  or  until  it  is  removed.  The  ligatures 
may  be  applied  in  the  wound  before  the  vessels  have  been  divided 
or  afterward,  and  may  be  applied  to  the  isolated  vessels  or  may  in- 
clude the  immediately  adjoining  soft  parts  as  well. 

Ligature  of  blood-vessels  before  they  have  been  severed  is  ex- 
emplified in  the  tying  of  the  external  jugular  in  operations  upon 
the  neck  after  the  vessel  has  been  exposed  in  the  incision,  but  before 
it  is  cut;  the  ligature  is  applied  double  and  the  vessel  then  divided 


SUTURE  OF  THE  TISSUES.  13 

between  these.  Again,  in  disarticulation  through  the  hip-joint  the 
main  vessels  may  be  exposed  during  the  course  of  the  operation, 
ligated,  and  then  divided.  In  resecting  portions  of  the  alimentary 
canal  the  mesentery  or  omentum  that  carries  the  blood-supply  to 
the  parts  must  be  tied  off.  This  is  usually  done  in  sections,  each 
ligature  including  from  one  to  one  and  a  half  inches  of  the  mesen- 
tery or  omentum;  in  this  case  not  only  are  the  blood-vessels  in- 
cluded in  the  ligatures,  but  all  of  the  tissue  from  one  ligature  to 
the  next. 

Ordinarily  the  ligatures  are  applied  to  the  vessels  after  they 
have  been  severed.  The  bleeding  point  is  seized  with  a  haemostatic 
forceps  and  the  ligature  is  then  slipped  over  the  end  of  this  and 
tied. 

Occasionally,  vessels  in  dense  fibrous  tissue,  in  the  dura  mater 
and  wall  of  the  chest,  when  cut,  retract  into  the  surrounding  tissue 
so  that  their  ends  cannot  be  seized  with  the  forceps.  Under  these 
circumstances  it  may  be  necessary  to  carry  the  ligature  around  the 
vessel  with  a  curved  needle. 


SUTURE  OF  THE  TISSUES. 

The  various  suture  materials  may  be  grouped  in  two  classes: 
temporary  and  permanent. 

Temporary  sutures  are  made  of  simple  catgut,  which  softens 
and  becomes  absorbed  in  from  five  to  ten  days  according  to  its  thick- 
ness, and  chromicized  catgut,  which  remains  longer,  from  two  to 
four  weeks  or  even  six  weeks,  according  to  its  thickness  and  the 
manner  of  its  preparation. 

Permanent  sutures  consist  of  silk,  silk-worm  gut,  kangaroo  ten- 
don, horse-hair  and  metal,  silver  wire,  etc.  (Kangaroo  tendon  be- 
comes absorbed  after  sixty  days;  so  that  it  is  not,  in  the  strict  sense, 
permanent.) 

Suture  of  the  Skin. — For  this  purpose  one  may  use  a  penetrating 
stitch,  continuous  or  interrupted,  or  a  non-penetrating  intercuticular 
stitch,  which  is  at  present  much  in  favor. 

The  stitch  should  not  be  drawn  too  tight,  as  it  constricts  the 
parts,  and  this  interferes  directly  with  the  blood-supply  and  the 
healing  process.  If  the  stitch  is  drawn  too  tight  it  may  cut  its  way 
through  the  tissues,  and  besides  may  add  much  to  the  pain  and 
discomfort  of  the  patient.     The  stitch  should  be  drawn  just  tight 


1-i 


GENERAL  CONSIDERATIONS. 


enough  to  bring  the  parts  into  immediate  contact.  The  knots  should' 
he  so  arranged  that  they  lie  to  one  side  or  the  other  of  the  wound. 

The  Lnteacuticular  Sutuee.  —  For  this  suture  simple  or 
chromicized  catgut  or  some  permanent  material — silk-worm  gut,  silk,. 
etc. — may  be  used.  It  may  be  introduced  with  a  straight  needle  or 
with  a  curved  needle  in  a  holder. 

In  introducing  this  stitch,  one  should,  with  the  needle,  catch 
the  firm  under  layer  of  the  skin  proper,  avoiding  the  loose,  sub- 
cutaneous fat  and  connective  tissue,  and  with  each  puncture  of  the 
needle  take  a  good  long  bite;   after  crossing  from  one  edge  of  the 


Fig.  7. — Intracuticular  Suture.     A,  end  of  suture  fixed  with  a  pledget  of  gauze. 


incision  to  the  other  one  should  take  care  to  enter  the  needle  directly 
opposite  the  point  at  which  it  emerged  or  even  a  trifle  back  of  this. 
The  suture  may  be  secured  at  each  end  with  a  small  pledget  of  gauze. 
One  pad  is  fixed  to  the  end  of  the  thread  before  commencing  the 
suture,  and  then,  after  the  needle  emerges  through  the  last  puncture, 
it  is  carried  through  the  second  pad  and  the  suture  secured  with  one 
or  two  turns  about  this. 

Suture  of  Muscle. — Divided  muscle  is  usually  approximated  with 
absorbable  material,  simple  or  chromicized  catgut.  If  the  muscle 
has  been  cut  across,  at  right  angles  to  the  course  of  its  fibers,  the 


SUTURE  OF  THE  TISSUES.  15 

part  should  be  placed  in  a  position  to  relax  the  muscle  and  special 
care  should  be  exercised  to  bring  the  cut  edges  securely  together. 
This  is  aceonrplished  by  introducing  a  sufficient  number  of  inter- 
rupted sutures  or  a  continuous  suture  of  moderately  thick  catgut, 
each  taking  a  good  secure  bite  in  the  muscle,  or  one  may  use  several 
mattress  sutures  for  this  purpose.  If  the  muscle  has  been  divided 
along  the  course  of  its  fibers, — i.e.,  between  its  fibers, — several  in- 
terrupted catgut  sutures  will  usually  suffice  to  retain  its  edges  in 
apposition. 

If  the  sheath  of  a  broad  muscle  has  been  divided, — for  exam- 
ple, the  sheath  of  the  rectus, — care  should  be  taken  to  unite  accu- 
rately, with  catgut,  simple  or  chromicized,  the  edges  of  the  sheath. 

In  operations  for  the  cure  of  hernias  the  edges  of  the  muscles 
are  sometimes  joined  with  a  non-absorbable  suture  material, — silk, 
silk-worm  gut,  or  silver  wire, — with  the  idea  of  leaving  these  as 
permanent  sutures  to  retain  the  parts  in  close  apposition. 


Fig.  8. — Bone  Drill  with  Eye  near  the  Point  to  carry  Suture,  etc. 

Suture  of  Tendons. — Severed  tendons  are  sewed  end  to  end  with 
some  absorbable  suture  material.  A  single  mattress  suture  or  one 
or  more  ordinary  interrupted  sutures  that  pass  through  the  tendon 
proper  are  usually  employed  for  this  purpose  (see  Fig.  198).  If  a 
part  of  the  tendon  has  been  destroyed  so  that  the  ends  cannot  be 
approximated,  a  flap  may  be  turned  back  from  one  or  both  ends  in 
order  to  meet  this  deficiency. 

Suture  of  Nerves. — The  ends  of  a  divided  nerve  may  be  joined 
with  one  or  two  catgut  sutures  which  secure  the  sheath  of  the  nerve, 
or,  better,  these  sutures  may  penetrate  the  nerve  proper. 

Bone  and  Cartilage. — For  the  purpose  of  suturing  bone  and 
cartilage  silver  wire  is  usually  employed.  Sometimes  heavy,  chro- 
micized catgut  is  used.  In  order  to  pass  the  sutures,  holes  must 
first  be  made  through  the  bone.  This  is  done  with  the  drill.  Before 
withdrawing  the  drill  the  suture  is  introduced  through  the  small 
eye  in  the  point  of  the  drill,  and  then  as  the  instrument  is  with- 
drawn it  brines  the  suture  after  it.     If  the  suture  is  too  thick  to 


16 


GENERAL  CONSIDERATIONS. 


enter  the  eye  in  the  point  of  the  drill,  one  may  pass  a  loop  of  silk 
through  the  eye  of  the  drill  and  with  this  draw  the  suture  through. 

Bones  are  sometimes  joined  with  one  or  more  sutures  of  chro- 
micized  catgut  which  do  not  go  through  the  bone,  but  include  the 
periosteum  and  the  fibrous  tissue  that  cover  the  bone;  this  method 
may  be  used,  for  example,  to  unite  a  fractured  patella  so  as  to  avoid 
entering  the  knee-joint  and  the  handling  that  would  be  necessary 
in  the  making  of  drill-holes. 

Bones  may  also  be  joined  by  steel  nails,  ivory  pegs,  etc.,  that 
are  driven  from  one  fragment  of  bone  into  the  other. 


Fig.  9.— Segment  of  Bowel.     Interrupted 
Lembert  sutures  in  place. 


Fig.  10.— Segment  of  Bowel.  Lembert 
sutures  tied.  It  will  be  noted  that  they 
do  not  penetrate  through  the  entire 
thickness  of  the  wall  of  the  gut. 


Suture  of  Serous  Surfaces,  Bowel,  etc. — The  essential  object  is 
to  secure  rapid  adhesion  by  approximating  serous  surface  to  serous 
surface,  and  this  is  accomplished  by  means  of  the  Lembert  suture. 

The  Lembert  suture  catches  the  serous  and  muscular  coats  of 
the  bowel,  but  does  not  penetrate  into  the  mucous  membrane  layer. 
It  should  not  enter  into  the  cavity  of  the  gut,  etc.  For  this  suture 
silk  should  be  employed.  It  may  be  introduced  interrupted  or  con- 
tinuous, and  is  applied  in  such  a  manner  as  to  invert  the  edges  and 
join  opposite  serous  surfaces. 

A  straight  round  cambric  needle  is  usually  employed  to  carry 
the  Lembert  suture,  but  occasionally,  especially  in  sewing  deep 
within  the  abdominal  cavity,  a  thin  curved  surgeon's  needle  in  a 
holder  may  be  more  convenient. 


SUTURE  OF  THE  TISSUES. 


17 


In  applying  the  Lembert  suture  the  needle  is  introduced  a  short 
distance  from  the  edge  of  the  wound,  and  after  passing  through  the 
wall  of  the  gut,  catching  up  the  serous  and  muscular  coats,  hut  not 
entering  the  mucous  membrane  coat,  it  emerges  near  the  edge  of 
the  incision;  the  needle  is  then  carried  across  the  incision  and  in- 
troduced upon  the  opposite  side  at  a  point  directly  opposite  and  in 
a  similar  manner. 

The  suture  may  also  be  introduced  and  carried  in  the  wall  of 
the  gut  along  a  line  parallel  with  the  incision  instead  of  at  right 
angles  to  the  line  of  the  incision. 


Fig.  11.— Cushing  Suture  Applied  to  Close  Opening  in  the  Bowel.  It  is  a 
continuous  stitch  and  passes  through  the  wall  of  the  gut  parallel  with  the 
line  of  the  incision  instead  of  at  right  angles  to  it. 


Small  wounds  of  the  bowel  may  be  closed  with  a  single  row  of 
Lembert  sutures.  Larger  wounds  of  the  hollow  abdominal  viscera 
should  be  closed,  first,  with  a  continuous  or  interrupted  row  of  silk 
or  catgut  sutures  that  penetrate  through  all  the  layers  of  the  organ, 
joining  the  parts  accurately  edge  to  edge,  and  then,  after  the  open- 
ing has  been  thus  closed,  the  Lembert  stitch,  which  unites  the 
opposite  serous  surfaces  to  each  other,  is  applied.  The  Lembert 
stitch  buries  the  penetrating  suture  and  inverts  the  edges  of  the 
wound,  so  that  the  serous  surfaces  become  apposed  to  each  other. 
The  outside  Lembert  suture  that  buries  the  deeper  penetrating 
mucous  suture  is  sometimes  called  the  "outside  serous"  suture. 


18  GENERAL  CONSIDERATIONS. 

Suture  of  Wounds  of  the  Bladder. — Closure  of  wounds  of 
the  urinary  bladder  requires  special  mention.  They  may  involve 
the  serous  or  the  non-serous  portion  of  the  organ. 

Wounds  of  the  serous  portion  should  he  first  closed  with  a 
continuous  catgut  stitch,  which  should  include  all  the  coats  except 
the  mucous  membrane.  Each  loop  of  this  suture  should  be  drawn 
tight.  This  serves  to  close  the  opening.  A  continuous  Lembert 
stitch  of  silk  is  then  introduced  which  unites  the  opposite  serous 
surfaces,  immediately  adjacent  to  the  edges  of  the  incision,  to  each 
other  and  buries  the  first  row  of  sutures. 

Wounds  of  the  non-serous  portion  of  the  bladder:  i.e.,  its  ante- 
rior wall.  Wounds  of  this  part  of  the  bladder  should  be  closed  with 
a  continuous  or  interrupted  row  of  catgut  sutures  that  include  the 
whole  thickness  of  the  bladder  wall  except  its  mucous  membrane. 
These  sutures  should  close  the  opening  in  the  wall  of  the  bladder 
very  accurately;  owing  to  the  absence  of  the  serous  coat  from  this 
part  of  the  bladder,  the  Lembert  suture — "outside  serous  suture" — 
cannot  be  applied.  Since  we  cannot  look  for  rapid  adhesion  in  wounds 
of  this  part  of  the  bladder,  it  is  well  to  allow  the  abdominal  incision 
to  remain  open,  packing  with  gauze  down  to  the  suture  line  in  the 
wall  of  the  bladder,  so  that,  if  there  is  any  leakage,  the  fluid  may 
find  its  way  out  of  the  wound. 


PART  II. 

HEAD    AND     FACE. 


HEAD. 


Surgical  Anatomy  of  the  Head.  The  Scalp. — The  head  is  cov- 
ered by  the  scalp,  which  is  a  dense  layer,  composed  of  the  skin, 
subcutaneous  connective  tissue,  and  the  aponeurosis  of  the  occipito- 
frontalis  muscle.     These  three  layers  together  constitute  the  scalp. 

The  subcutaneous  connective  tissue  is  dense  and  serves  to  unite 
the  skin  intimately  with  the  underlying  aponeurosis  of  the  occipito- 
frontalis  muscle.  It  is  continuous  behind,  in  front,  and  upon  the 
sides  with  the  superficial  fascia  (subcutaneous  fatty  and  connective 
tissue  layer)  of  these  parts.  In  it  ramify  the  blood-vessels  and 
nerves. 

The  arteries  of  the  scalp  are  large  and  numerous.  Bleeding 
from  these  vessels  can  often  be  controlled  by  pressure  applied  against 
the  underlying  bony  surface.  Anteriorly  are  the  frontal  and  supra- 
orbital arteries;  on  the  sides,  branches  of  the  temporal;  and,  behind, 
the  occipital  and  posterior  auricular.  These  vessels  all  course  from 
below  upward  toward  the  crown  of  the  head,  their  branches  anas- 
tomosing freely  with  each  other  all  around.  These  arteries  are 
found  at  times  to  be  very  tortuous. 

The  occipito-frontalis  muscle  is  broad  and  flat,  consisting  of 
an  anterior  and  a  posterior  muscular  portion  and  an  intermediate 
aponeurotic  portion  which  covers  the  top  of  the  skull.  This  apo- 
neurosis is  firmly  united  with  the  overlying  skin,  whereas  it  is  but 
loosely  attached  to  the  pericranium  beneath.  Upon  either  side  the 
aponeurosis  is  continued  into  the  temporal  fascia.  In  cases  where 
the  scalp  is  torn  off,  the  aponeurosis  of  the  occipito-frontalis  comes 
away  with  the  skin  and  subcutaneous  connective  tissue,  thus  leaving 
the  pericranium  exposed. 

In  the  temporal  region  the  subcutaneous  connective  tissue  layer 
is  looser  than  upon  the  top  of  the  head,  and  in  it  run  the  branches 
of  the  temporal  artery  and  vein  and  the  auriculo-temporal  nerve. 
Beneath  the  subcutaneous  layer  in  the  temporal  region  is  the  tem- 
poral fascia.    This  is  a  strong,  fibrous  layer  covering  in  the  temporal 

(19) 


20  HEAD  AND  FACE. 

muscle,  and  is  attached  above,  all  around,  to  the  temporal  ridge, 
and,  below,  to  the  upper  border  of  the  zygomatic  arch,  where  it  splits 
into  two  layers,  between  which  are  included  a  small  arterial  and 
nervous  branch.  The  aponeurosis  of  the  occipito-frontalis  muscle 
thins  out  upon  each  side  and  is  continued  into  this  temporal  fascia. 
Beneath  the  temporal  fascia  is  the  temporal  muscle.  This  is  a  broad, 
fan-shaped  muscle  which  arises  from  the  whole  surface  of  the  tem- 
poral fossa  and  from  the  under  surface  of  the  temporal  fascia;  it  is 
attached  by  a  strong  tendon  to  the  tip,  anterior  border,  and  inner 
surface  of  the  coracoid  process  of  the  inferior  maxilla. 

The  pericranium  is  a  shining,  fibrous  layer  of  periosteum  which 
is  closely  attached  to  the  external  surface  of  the  bones  of  the  skull: 
most  intimately  at  the  suture  lines,  through  which  it  is  continuous 
with  the  dura  mater  lining  the  inner  surface  of  the  bones. 

Collections  of  pus  or  blood  between  the  skin  and  the  occipito- 
frontalis  aponeurosis  give  rise  to  circumscribed  tumors  because  they 
cannot  become  diffused  in  the  dense  subcutaneous  connective  tissue 
layer.  Between  the  aponeurosis  and  the  pericranium,  however,  such 
collections  may  become  widely  diffused,  owing  to  the  looseness  of  the 
tissue  which  joins  the  aponeurosis  and  the  pericranium  together, 
and,  raising  the  whole  scalp  so  that  it  resembles  a  water-bag,  may 
gravitate  and  point  in  the  frontal  or  occipital  regions.  Beneath  the 
pericranium,  between  this  layer  and  the  surface  of  the  bone,  such 
collections  are  again  limited,  owing  to  the  close  union  between  this 
structure  and  the  underlying  bone. 

The  Skull  is  a  rounded,  elastic  case  made  up  of  a  number  of 
bones  joined,  for  the  most  part,  edge  to  edge.  The  base  of  the 
skull  is  irregular  and  is  strengthened  along  certain  lines  by  ribs  of 
bone,  the  intervening  portions  being  often  very  thin.  It  presents 
many  openings  for  the  entrance  and  exit  of  important  structures. 
The  vault  of  the  skull  is  arched,  rounded,  and  smooth.  The  bones 
entering  into  the  formation  of  the  vault  are  flat  and  vary  in  thick- 
ness in  different  places.  These  so-called  flat  bones  that  enter  into 
the  formation  of  the  vault  are  made  up  of  spongy  tissue — diploe — 
inclosed  between  two  plates  of  hard  compact  bone:  the  inner  and 
outer  tables.  The  outer  table  is  twice  as  thick  as  the  inner.  The 
external  surface  of  the  skull  is  covered  by  the  periosteum  (peri- 
cranium) already  mentioned.  The  internal  surface  is  lined  by  the 
dura  mater,  which  is  very  closely  applied  to  the  surface  of  the  bones, 
serving  the  purpose  of  a  periosteum;    the  large  vascular  branches 


SURGICAL  ANATOMY  OF  THE  HEAD.  21 

that  ramify  upon  the  inner  surface  of  the  skull  are  lodged  in  the 
dura. 

The  spongy  substance — diploe' — inclosed  between  the  two  layers 
of  compact  bone  presents  an  extensive  system  of  venous  canals. 
These  communicate  with  the  intracranial  venous  channels,  that  are 
found  between  the  layers  of  the  dura  mater,  and  with  the  veins  of 
the  scalp.  The  vault  of  the  skull  varies  in  thickness  in  different 
places  and  in  different  individuals.  About  the  middle  it  is  thin,  its 
average  thickness  in  this  situation  being  from  4  to  5  mm.;  it  be- 
comes thicker  toward  the  front  and  still  more  so  toward  the  occiput. 
Along  the  course  of  the  intracranial  venous  sinuses,  and  also  corre- 
sponding to  the  depressions  for  the  Pacchionian  bodies,  which  are 
located  upon  either  side  along  the  middle  line,  the  bone  is  thinner. 
"Where  the  skull  is  thin  it  is  at  the  expense  of  the  diploe,  which  in 
certain  parts  may  be  entirely  absent,  the  two  tables  being  in  direct 
contact  with  each  other.  This  is  the  condition  in  the  temporal 
region. 

Corresponding  to  the  frontal  region  the  skull  is  marked  by  the 
presence  of  two  large  air-spaces,  one  on  either  side,  the  frontal 
sinuses;  these  are  separated  from  each  other  by  a  septum  located 
more  or  less  in  the  middle  line.  The  anterior  wall  of  these  spaces 
is  thick,  and  consists  of  two  layers  of  hard,  compact  bone  with  inter- 
vening diploe.  The  posterior  wall  is  thin.  The  frontal  sinuses  vary 
in  size  in  different  individuals,  are  lined  with  mucous  membrane, 
and  communicate  with  the  nasal  fossa  through  a  large  canal,  the 
infundibulum,  which  opens  under  the  middle  turbinated  bone, 
toward  the  front. 

In  the  mastoid  region  the  bone  is  prolonged  downward  in  the 
form  of  a  teat-like  process:   the  mastoid  process. 

Corresponding  to  the  temporal  region,  the  skull  is  made  up  of 
the  squamous  portion  of  the  temporal  bone,  which  is  very  thin,  and 
of  part  of  the  parietal  bone.  Ascending  upon  the  surface  of  the 
bone,  beneath  the  temporal  muscle,  are  several  deep  temporal  arte- 
rial branches. 

The  parietal  and  the  occipital  bones  and  the  mastoid  portion 
of  the  temporal  bone  present  openings  for  the  passage  of  veins  from 
the  exterior  of  the  skull  which  empty  into  the  intracranial  sinuses, 
and  these  may  be  the  routes  through  which  infection  is  carried  into 
the  cranial  cavity. 

The  Dura  Mater  is  a  strong,  non-elastic,  fibrous  membrane 


22  HEAD  AND  FACE. 

which  lines  the  inner  surface  of  the  skull  and  is  closely  attached 
to  the  hones  (periosteum),  but  may  be  separated  without  much  force. 
It  supports  the  intracranial  arteries  and  veins  (venous  sinuses),  and 
when  separated  from  the  surface  of  the  bones  carries  these  vessels 
with  it.  Anteriorly,  ramifying  in  the  dura  mater,  is  the  anterior 
meningeal  artery,  which  is  a  branch  of  the  ethmoid.  Corresponding 
to  the  middle  fossa  of  the  skull  and  the  temporal  region,  the  middle 
meningeal  artery  is  found.  This  is  a  branch  of  considerable  size, 
and  is  of  much  surgical  importance;  it  is  derived  from  the  internal 
maxillary  and  enters  the  skull  through  the  foramen  spinosum  in  the 
base  of  the  skull.  Behind  are  the  posterior  meningeal  branches 
which  are  derived  from  the  occipital  and  the  vertebral. 

There  are  a  number  of  large  venous  sinuses  which  are  situated 
between  the  layers  of  the  dura  and  which  groove  the  surface  of  the 
bones  along  their  course.  The  largest  of  these  are  the  longitudinal, 
the  lateral,  and  the  cavernous. 

The  longitudinal  sinus  runs  from  before  backward  along  the 
line  of  the  sagittal  suture  from  the  foramen  caecum  in  front  to  the 
occipital  protuberance  behind. 

The  lateral  sinus  is  important  surgically.  From  the  center  of 
the  occipital  bone  that  of  either  side  passes  transversely  outward, 
grooving  the  internal  surface  of  the  occipital  bone  upon  a  line  cor- 
responding to  the  attachment  of  the  trapezius  and  sterno-mastoid 
muscles  and  the  inner  surface  of  the  posterior  inferior  corner  of  the 
parietal;  here  the  sinus  curves  downward,  grooving  the  inner  sur- 
face of  the  mastoid,  and  from  this  bone  is  continued  again  over  on 
to  the  occipital,  crossing  the  upper  surface  of  the  jugular  process 
of  this  bone,  to  join  with  the  inferior  petrosal  sinus  to  form  the 
internal  jugular  vein.  The  course  of  the  transverse  portion  of  the 
lateral  sinus  corresponds  to  a  line  drawn  from  the  external  occipital 
protuberance  to  the  upper  margin  of  the  external  auditory  meatus. 

The  cavernous  sinus  is  lodged  in  the  groove  upon  the  side  of 
the  body  of  the  sphenoid  bone.  The  internal  carotid  artery  passes 
from  behind  forward,  from  the  orifice  of  the  carotid  canal  in  the 
apex  of  the  petrous  portion  of  the  temporal  bone,  where  the  artery 
enters  the  cranium,  to  the  point  where  it  divides  into  its  terminal 
branches.  This  part  of  the  internal  carotid  artery  is  enveloped  by 
the  cavernous  sinus,  the  wall  of  the  sinus  being,  as  it  were,  wrapped 
around  the  artery.  The  sixth  nerve  is  also  inclosed  entirely  within 
the  sinus,  lying  below  and  to  the  outer  side  of  the  artery.    The  third, 


OPERATIONS  UPON  THE  HEAD.  23 

fourth,  and  the  ophthalmic  division  of  the  fifth  nerve  are  located 
in  the  outer  wall  of  the  cavernous  sinus,  but  are  not  contained  within 
its  lumen  as  are  the  internal  carotid  artery  and  the  sixth  nerve. 

The  blood-pressure  within  these  sinuses  is  low,  and  hemorrhage 
is  readily  controlled  by  packing  with  gauze. 

The  Pia  Mater. — The  skull  contains  the  brain  inclosed  within 
its  own  peculiar  membrane:  the  pia  mater.  This  is  a  connective 
tissue  membrane  which  serves  to  support  the  vessels  which  supply 
the  brain,  and  contains  within  its  meshes  the  cerebro-spinal  fluid. 
The  pia  mater  is  not  a  simple  flat  membrane,  but  is  really  made  up 
of  two  layers  joined  together  by  septa  which  divide  it  up  into  a 
mesh-work  of  cellular  spaces  within  which  is  contained  the  cerebro- 
spinal fluid.  It  has  been  compared  to  a  water-soaked  connective 
tissue.  It  has  no  connection  with  the  dura  mater;  so  that  between 
the  inner  surface  of  the  dura  and  the  external  surface  of  the  pia 
there  is  a  narrow  free  space,  or  crevice,  which  contains  a  minute 
quantity  of  fluid.     This  is  called  the  subdural  space. 

Between  the  layers  of  the  pia  mater  there  is  a  great  system 
of  spaces  communicating  with  each  other,  and  this  is  sometimes 
called  the  subarachnoid  space;  as  already  stated,  the  cerebro-spinal 
fluid  is  contained  in  this  space.  This  membrane,  the  pia  mater,  is 
attached  by  its  deep  internal  surface  directly  to  the  surface  of  the 
brain,  dipping  down  between  its  convolutions  and  lobes.  It  acts 
like  a  water  cushion,  preserving  the  blood-vessels  from  pressure,  and 
also  permits  intracranial  tumors,  etc.,  to  acquire  an  appreciable 
thickness  before  they  begin  to  cause  pressure  symptoms. 

OPERATIONS  UPON  THE  HEAD. 

Trephining. — By  trephining  we  mean  making  an  opening  into, 
or  resecting  a  portion  of,  the  skull.  This  operation  is  done  to  relieve 
compression  either  from  depressed  bone  or  from  extravasated  blood, 
and  to  treat  intracranial  conditions,  as  abscess,  tumor,  etc. 

The  patient  is  placed  upon  the  back  with  a  thin  sand  bag  under 
the  head.  The  opening  in  the  skull  may  be  made  with  a  trephine, 
chisel,  or  rongeur  or  Keen  forceps,  or  with  a  circular  saw  or  a 
rotary  drill. 

Trephining  for  Depressed  Fracture  of  the  Skull. — If  a 
wound  is  already  present,  this  should  be  utilized,  and,  if  necessary, 
may  be  enlarged  in  order  to  expose  the  site  of  fracture.    If  no  wound 


24  HEAD  AND  FACE. 

is  present  and  the  incision  is  a  matter  of  choice,  a  crescentic  or 
crucial  incision  may  be  employed,  or  a  U-shaped  flap  be  reflected. 
In  marking  out  this  flap  the  base  should  be  below,  toward  the  pe- 
riphery, so  as  to  insure  good  blood-supply  to  the  flap.  The  incision 
should  reach  through  the  periosteum  down  to  the  surface  of  the 
bone,  and  in  reflecting  the  flap  the  periosteum  should  be  included. 

After  the  site  of  the  fracture  has  been  exposed  and  spurting 
vessels  clamped  and  tied,  one  may  proceed  to  relieve  the  compression 
by  elevating  depressed  bone,  clearing  out  blood-clot,  etc.  A  num- 
ber of  loose  pieces  of  bone,  entirely  detached  from  the  periosteum 
(pericranium  and  dura  mater),  may  be  found,  and  these  may  be 
removed  with  a  thumb  forceps.  We  may  find  other  fragments  loose, 
but  still  attached,  at  least  in  part,  to  the  periosteum  or  dura  mater. 
These  may,  in  some  cases,  be  readily  elevated.  We  may  find  other 
depressed  fragments  so  firmly  impacted,  wedged,  that  they  cannot 
be  elevated,  and  in  order  to  get  at  these  fragments  it  may  be  neces- 
sary to  remove  a  portion  of  the  adjoining  margin  of  bone,  either 
with  the  trephine  or  chisel.  If  the  trephine  is  used  for  this  purpose 
the  periosteum  is  scraped  back,  laying  bare  the  surface  of  the  bone 
which  is  to  be  removed.  When  the  trephine  is  first  applied  the 
center  pin  should  be  lowered  beyond  the  level  of  the  cutting  edge 
of  the  crown  of  the  trephine,  so  as  to  engage  in  the  bone  and  steady 
the  trephine  until  the  crown  has  cut  a  groove  within  which  it  may 
work  without  slipping,  when  the  pin  may  be  again  raised.  The 
trephine  should  be  so  placed  that  its  crown  will  partly  overlap  the 
edge  of  the  bone,  so  that  only  one-half  of  a  button  will  be  removed 
from  the  margin  adjoining  the  impacted  fragment.  The  trephine 
should  be  worked  with  a  firm,  steady  wrist  movement,  and  the  groove 
occasionally  probed  to  ascertain  if  the  bone  is  cut  through  at  any 
point.  The  use  of  such  force  as  would  result  in  sudden,  abrupt 
penetration  of  the  skull  should  be  avoided.  The  button  may  be 
loosened  by  gently  prying  with  the  elevator.  Bleeding  from  the 
edge  of  the  bone  ceases  after  a  few  moments'  pressure  with  a  hot 
gauze  pad. 

In  many  cases  the  liberation  of  an  impacted  fragment  is  best 
accomplished  by  using  the  chisel  to  cut  away  the  margin  of  the 
bone  that  holds  it  fast;  often,  with  a  few  strokes  of  the  mallet,  the 
fragment  is  freed  or  a  space  is  made  to  allow  the  use  of  the  elevator. 

Having  removed  all  loose  fragments  and  elevated  those  which 
are  still  attached  to  the  pericranium  and  dura  mater  and  rounded  off 


OPERATIONS  UPON  THE  HEAD.  25 

the  edges  of  any  defect  left  in  the  skull,  one  should  search  carefully 
for  any  loose  fragments  or  spiculge  which  may  he  concealed  under 
the  edge  of  the  opening  in  the  hone.  The  finger  or  prohe  should 
be  used  for  this  purpose.  Small  pieces  may  he  washed  out  by  irri- 
gation with  a  weak  bichloride  solution  or  they  may  be  picked  out 
with  a  forceps.  One  should  examine  carefully  as  to  the  condition 
of  the  internal  table,  as  this  is  often  more  extensively  fractured 
than  is  indicated  by  the  appearance  of  the  external  table.  The 
internal  table  is  at  times  extensively  fractured  and  depressed  when 
the  corresponding  part  of  the  external  table  is  apparently  uninjured. 
Extravasated  clotted  blood,  between  the  dura  and  the  inner  surface 
of  the  bone,  or  beneath  the  dura,  between  it  and  the  pia  mater, 
should  be  removed  with  a  scoop  and  by  irrigation  and  any  severed 
vessels  tied  with  fine  catgut.  If  the  dura  mater  has  been  torn  the 
edges  of  the  opening  may  be  brought  together  with  a  fine  catgut 
suture. 

The  wound  in  the  scalp  may  be  closed  without  drainage  unless 
the  parts  have  been  exposed  to  the  chance  of  infection.  In  this  case, 
for  the  purpose  of  drainage,  a  narrow  strip  of  gauze  may  be  intro- 
duced through  one  corner  of  the  wound  and  reaching  down  to  the 
dura  mater. 

Trephining  for  Intracranial  Hemorrhage  (Middle  Men- 
ingeal). —  The  middle  meningeal  artery  is  the  usual  source  of 
traumatic  intracranial  hemorrhage. 

The  middle  meningeal  is  a  vessel  of  considerable  size,  and  is 
given  off  from  the  upper  aspect  of  the  first  part  of  the  internal 
maxillary  a  short  distance  beyond  its  origin  from  the  external 
carotid,  as  it  (the  internal  maxillary)  lies  beneath  the  neck  of  the 
condyle  of  the  jaw,  between  it  and  the  internal  lateral  ligament. 
The  middle  meningeal  passes  directly  upward  between  the  two  roots 
of  the  auriculo-temporal  nerve,  which  surround  the  commencement 
of  the  artery,  toward  the  base  of  the  skull,  and  enters  the  skull 
through  the  foramen  spinosum.  This  part  of  the  middle  meningeal 
artery  is  concealed  beneath  the  external  pterygoid  muscle,  the  ten- 
don of  which  is  attached  to  the  front  of  the  neck  of  the  condyle 
of  the  jaw.  In  front  and  internal  to  this  part  of  the  artery  is  the 
inferior  maxillary  division  of  the  fifth  nerve  and  its  motor  root,  these 
nerve  branches  emerging  from  the  skull  through  the  foramen  ovale. 

After  entering  the  skull  the  middle  meningeal  runs  a  short 
distance  outward  in  a  groove  in  the  floor  of  the  middle  fossa  and 


26  HEAD  AND  FACE. 

then  divides  into  two  branches.  The  anterior,  the  larger  branch, 
passes  forward  and  outward  across  the  floor  of  the  middle  fossa  of 
the  skull  and  across  the  anterior  inferior  angle  of  the  parietal  bone 
just  behind  the  outer  extremity  of  the  lesser  wing  of  the  sphenoid, 
and  may  be  exposed  as  it  ascends  upon  the  side  of  the  skull  at  a 
point  which  corresponds  to  the  intersection  of  two  lines  (Vogt), 
one  vertical,  a  thumb's  breadth  behind  the  external  angular  process, 
and,  the  other,  horizontal,  placed  two  fingers'  breadth  above  the 
z}rgoma.  The  posterior  branch  of  the  middle  meningeal  passes  out- 
ward across  the  squamous  portion  of  the  temporal  bone  and  then 
ascends  upward  and  backward  upon  the  inner  surface  of  the  poste- 
rior inferior  portion  of  the  parietal  bone  above  and  in  front  of  the 
groove  seen  here  for  the  lateral  sinus.  The  posterior  branch  may 
be  exposed  by  removing  a  button  of  bone  whose  center  is  one  inch 
above  and  one-half  inch  behind  the  external  auditory  meatus. 

The  middle  meningeal  and  its  branches  ramify  in  the  dura  and 
groove  the  surface  of  the  bones  against  which  they  are  applied.    The 


.s^v^^^^-^-.^^^^^^ 


^ 


Fig.  12.— Hartley  Chisel.     This  chisel  is  pointed,  V  shape  en  section,  and  is 
very  convenient  for  cutting  the  groove  in  the  bone. 

anterior  branch,  as  it  approaches  the  anterior  inferior  angle  of  the 
parietal  bone,  is  lodged  in  a  deep  groove,  which  is  occasionally  con- 
verted into  a  complete  bony  canal. 

Temporary  Resection  of  the  Skull.  —  When  the  skull  is  intact, 
it  is  preferable,  in  order  to  gain  access  to  the  cranial  cavity,  to  do 
a  temporary  resection  of  the  skull  (Wagner),  turning  back  a  flap, 
which  consists  of  the  soft  parts,  periosteum,  and  corresponding 
piece  of  bone,  rather  than  to  remove  a  button  of  bone,  which  leaves 
a  permanent  defect  in  the  skull.  To  reach  the  middle  meningeal 
artery  or  its  divisions  this  is  a  most  satisfactory  method. 

A  horseshoe-shaped  flap  is  marked  out  in  the  temporal  region, 
with  its  arch  above  and  its  base  below  at  the  zygoma,  the  anterior 
leg  being  placed  a  good  finger's  breadth  behind  the  external  angular 
process  and  the  posterior  leg  just  in  front  of  the  tragus.  The  in- 
cision should  reach  through  the  soft  parts,  including  the  periosteum, 
down  to  the  bone.  The  flap  thus  marked  out  should  measure  in  its 
vertical  diameter  about  three  inches,  and  about  two  and  one-half 


OPERATIONS  UPON  THE  HEAD. 


27 


inches  across  its  widest  part.  At  its  base  the  flap  should  be  from 
one  and  one-half  to  two  inches  wide. 

The  temporal  artery  and  some  of  its  branches  are  usually 
divided,  and  must  be  clamped  and  tied. 

Betracting  the  soft  parts,  but  without  separating  them  from 
the  surface  of  the  bone,  a  groove  is  cut  in  the  bone  all  around  corre- 
sponding to  the  course  of  the  skin  incision.     This  may  be  accom- 


Fig.  13. — Temporary  Resection  of  the  Skull.  Osteo-tegumentary  flap 
turned  down,  exposing  dura.  MA,  anterior  branch  of  middle  meningeal  ar- 
tery.   MP,  posterior  branch  of  middle  meningeal  artery. 


"plished  with  a  chisel  (Hartley  or  ordinary  chisel),  or  one  may  com- 
mence by  marking  it  out  with  a  revolving  saw  and  complete  it  with 
the  chisel,  or  a  small  opening  may  be  made  in  the  skull  with  a 
trephine  and  a  rotary  drill  then  used.  The  line  of  section  through 
the  bone  should  not  be  direct,  but  rather  somewhat  oblique,  so  that 
the  segment  of  bone  in  the  flap  may  have  a  beveled  edge,  thus  giving 
a  better  fit  when  it  is  replaced.    After  the  section  through  the  bone 


28  HEAD  AND  FACE. 

has  been  made,  the  periosteum  elevator  is  introduced  into  the  upper 
part  of  the  groove  and  the  piece  of  bone  pried  out,  breaking  it  below,, 
through  its  base,  near  the  zygoma,  and  then  this  flap,  which  consists- 
of  all  the  soft  parts  with  the  corresponding  segment  of  bone  attached, 
is  turned  down  over  the  zygoma,  leaving  a  considerable  opening  in 
the  skull  through  which  the  dura  mater  and  the  branches  of  the 
middle  meningeal  artery,  which  ramify  in  it,  are  exposed. 

If  the  opening  in  the  skull  is  not  sufficiently  large,  it  may  be 
further  enlarged  by  cutting  away  its  margins  with  the  bone  forceps. 

The  extravasated  blood  is  usually  located  between  the  dura  and 
the  bone,  so  that  as  soon  as  the  plate  of  bone  has  been  turned  back 
we  expose  the  blood,  which  is,  as  a  rule,  partly  clotted.  This  may 
be  cleared  out  with  a  scoop  and  irrigation,  after  which  the  ends  of 
the  divided  vessel  are  sought  and  tied.  Ordinarily  they  may  be 
seized  with  a  clamp  and  ligated  in  the  usual  manner;  there  may, 
however,  be  some  difficulty  in  securing  the  ends  of  the  divided  ves- 
sel, as  they  may  have  retracted  within  the  canal  in  the  dura  in  which 
they  are  situated  to  such  an  extent  that  they  cannot  be  readily  seized 
with  the  artery  forceps,  and  it  may  then  be  necessary  to  carry  a 
ligature  around  the  vessel  with  a  curved  needle. 

Should  the  blood  have  collected  beneath  the  dura  mater,  be- 
tween it  and  the  surface  of  the  brain  (pia  mater),  in  the  subdural 
space,  it  would  be  necessary  to  make  an  opening  in  the  dura  in 
order  to  clear  the  blood  out. 

Usually  the  anterior  branch  of  the  middle  meningeal  is  the 
vessel  which  is  torn,  but  through  the  opening  made  in  the  skull  one 
can  also  reach  the  posterior  branch  or  the  main  trunk  if  necessary. 

Having  entirely  removed  the  blood,  tied  the  ruptured  vessel, 
and  sutured  the  dura,  if  it  has  been  incised  or  torn,  we  replace  the 
osteo-tegumentary  flap  and  without  drainage  unite  the  edges  of  the 
soft  parts  all  around  with  interrupted  catgut  sutures. 

Removal  of  a  Button  of  Bone  with  the  Trephine. — By  removing 
a  button  of  bone  with  the  trephine  the  anterior  and  posterior 
branches  of  the  middle  meningeal  may  be  exposed  and  ligated. 

To  reach  the  anterior  branch  of  the  middle  meningeal,  an  in- 
cision, vertical,  is  made  through  the  skin,  muscle,  and  periosteum 
down  to  the  bone,  and  with  the  periosteum  elevator  the  surface  of 
the  bone,  corresponding  to  the  intersection  of  Vogt's  lines,  is  laid 
bare  (see  Fig.  16).  Instead  of  using  the  vertical  incision  this  area 
of  bone  may  be  exposed  by  turning  down  a  U-shaped  flap  with  its- 


OPERATIONS  UPON  THE  HEAD.  29 

base  below  near  the  zygoma.  This  flap  includes  all  the  tissues  of 
the  scalp  and  the  periosteum,  and  is  detached  from  the  surface  of 
the  bone  with  an  elevator. 

The  trephine  is  then  used  to  remove  a  button  of  bone,  and 
thus  the  dura  is  exposed.  If  the  opening  is  not  sufficiently  large  it 
may  be  enlarged  with  the  rongeur  bone  forceps.  The  clot  is  usually 
found  between  the  dura  and  the  bone,  and  is  therefore  exposed  as 
soon  as  the  button  has  been  removed.  It  may,  however,  be  situated 
beneath  the  dura,  in  the  subdural  space,  and  it  may  thus  become 
necessary  to  incise  the  dura  in  order  to  reach  it.  After  clearing  out 
the  clot,  etc.,  the  ends  of  the  vessels  are  secured  and  the  incision  in 
the  soft  parts  closed.  This  operation  may  be  performed  more  quickly 
than  the  temporary  resection  of  the  skull,  but  it  does  not  give  as 
much  room,  and  a  further  disadvantage  is  that  it  usually  leaves  a 
permanent  defect  in  the  skull. 

To  expose  the  posterior  branch  of  the  middle  meningeal  a 
button  of  bone  may  be  removed  one  inch  above  and  one-half  inch 
posterior  to  the  external  auditory  meatus,  as  described  above.  This 
branch  is  but  seldom  injured. 

Craniectomy  (Lineae  Ceaniotomy). — Making  linear  furrows 
in  the  skull  for  the  purpose  of  providing  space  to  permit  of  the  proper 
growth  of  the  brain,  in  cases  of  microcephalia  and  idiocy. 

This  operation  was  first  performed  by  Lannelongue.  It  may 
be  done  on  one  or  both  sides  of  the  skull  at  one  sitting:  one  side 
at  a  time  is  probably  preferable. 

A  longitudinal  incision  is  made  in  the  scalp  in  the  middle  line 
commencing  at  a  point  just  above  the  occipital  protuberance  and 
carried  forward  as  far  as  the  hair-line  of  the  scalp;  from  the  ante- 
rior end  of  this  a  second  curved  incision  may  be  made  reaching 
downward  and  outward  away  from  the  middle  line;  this  latter  in- 
cision is  also  placed  within  the  hair-line  of  the  scalp.  The  scalp 
is  then  raised  from  the  skull  with  the  elevator. 

Posteriorly,  just  above  the  occipital  protuberance,  an  opening 
is  made  in  the  skull  with  the  trephine,  about  one-half  inch  in  diam- 
eter, and  through  this  opening,  with  the  bone  forceps,  a  furrow  is 
cut  which  is  carried  forward  to  within  an  inch  of  the  supra-orbital 
ridge.  This  channel  should  be  about  one-fourth  of  an  inch  wide 
and  will  vary  from  five  to  six  and  one-half  inches  in  length  and 
should  be  placed  about  three-fourths  of  an  inch  away  from  the 
middle  line,  in  order  to  avoid  the  longitudinal  sinus.     The  dura  is 


30  HEAD  AND  FACE. 

detached  from  the  inner  surface  of  the  skull  to  permit  the  use  of 
the  hone  forceps,  but  should  not  be  opened. 

From  either  end  of  the  longitudinal  furrow  in  the  bone  an 
additional  channel  may  be  cut,  reaching  downward  and  outward  for 
one  or  two  inches  away  from  the  middle  line. 

The  periosteum  is  cut  away  from  the  margins  of  the  furrows 
in  the  bone  to  prevent  reproduction  of  the  bone.  If  any  of  the 
branches  of  the  meningeal  are  injured  during  the  course  of  the 
operation,  they  may  be  surrounded  by  a  ligature  carried  in  a  curved 
surgeon's  needle  and  tied.  It  is  often  difficult  to  secure  these 
branches  with  the  artery  forceps,  and  thus  the  necessity  of  carrying 
the  ligature  around  them  in  the  needle. 

The  edges  of  the  incision  in  the  scalp  are  accurately  approxi- 
mated without  drainage,  to  insure  primary  healing. 

The  longitudinal  furrow  in  the  skull  is  usually  placed  to  the 
left  of  the  middle  line,  but  may  be  placed  upon  the  right  side  in- 
stead, if  this  appears  to  be  the  less  developed  side. 

THE  MIDDLE  FOSSA  OF  THE  SKULL. 

The  Anatomy  of  the  Middle  Fossa. — The  middle  fossa  of  the 
skull  is  narrow  in  the  middle  and  widens  out  upon  either  side.  It 
is  limited  in  front  by  the  posterior  border  of  the  lesser  wing  of  the 
sphenoid  and  by  the  optic  groove;  behind  by  the  dorsum  epiphii 
and  the  upper  border  of  the  petrous  portion  of  the  temporal  bone. 
The  upper  border  of  the  petrous  portion  is  marked  by  a  groove  for 
the  superior  petrosal  sinus  and  gives  attachment  to  the  tentorium 
cerebelli.  The  floor  of  the  middle  fossa,  in  the  middle  line,  consists 
of  the  upper  surface  of  the  body  of  the  sphenoid,  presenting  in 
front  the  optic  groove,  at  either  end  of  which  is  the  optic  foramen; 
behind  the  optic  groove  is  the  sella  turcica,  a  deep  depression  which 
lodges  the  pituitary  body  and  which  is  bounded  behind  by  the 
dorsum  epiphii;  laterally  the  floor  of  this  fossa  consists  of  the  upper 
surface  of  the  great  wing  of  the  sphenoid,  the  anterior  surface  of 
the  petrous  portion  of  the  temporal,  and  a  part  of  the  squamous 
portion  of  the  temporal.  The  body  of  the  sphenoid  is  marked  upon 
either  side  by  a  groove  which  commences  behind  at  the  foramen 
lacerum  medium  (carotid  foramen)  and  terminates  in  front  at  the 
optic  foramen.     This  lodges  the  cavernous  sinus,  etc. 

The  foramen  lacerum  medium  is  formed  at  the  expense  of  the 


ANATOMY  OF  THE  MIDDLE  FOSSA.  31 

anterior  superior  surface  of  the  apex  of  the  petrous  portion  of  the 
temporal;  it  is  bounded  in  front  by  the  posterior  border  of  the 
great  wing  of  the  sphenoid  and  behind  by  the  apex  of  the  petrous- 
portion;  through  this  opening  the  internal  carotid  artery  enters 
the  cranium.  Behind  and  external  to  this  foramen  the  antero- 
superior  surface  of  the  petrous  portion  presents  a  depression  in 
which  the  Casserian  ganglion  rests.  In  front  of  and  external  to 
the  foramen  laeerum  medium,  in  the  posterior  part  of  the  great 
wing  of  the  sphenoid,  there  is  a  large  opening,  the  foramen  ovale. 
As  its  name  indicates,  this  opening  is  oval  in  shape,  its  long  diam- 
eter being  directed  from  without  inward  and  a  little  forward.  This 
opening  is  seen  externally  upon  the  base  of  the  skull  at  the  root 
of  the  pterygoid  process,  external  to  the  external  pterygoid  plate. 
Through  this  opening  the  inferior  maxillary  or  third  division  of  the 
fifth  nerve  emerges  from  the  cranial  cavity.  Just  external  to  the 
foramen  ovale  and  a  little  behind  it,  in  the  apex  or  angle  of  the 
great  wing  of  the  sphenoid,  is  the  foramen  spinosum,  through  which 
the  middle  meningeal  artery  enters  the  skull.  From  this  opening 
a  groove  is  seen  running  outward,  marking  the  squamous  portion 
of  the  temporal  near  its  junction  with  the  petrous  portion;  this 
groove  lodges  the  posterior  branch  of  the  middle  meningeal  artery 
and  is  continued  upward  upon  the  side  of  the  skull  across  the  poste- 
rior inferior  part  of  the  parietal  bone.  Commencing  at  or  near  the 
foramen  spinosum  there  is  another  groove,  which  runs  forward  and 
outward  across  the  squamous  portion  of  the  temporal  and  the  great 
wing  of  the  sphenoid,  ascending  upon  the  side  of  the  skull,  across, 
the  anterior  inferior  portion  of  the  parietal  bone;  in  this  groove 
rests  the  anterior  division  of  the  middle  meningeal  artery.  About 
one-half  inch  in  front  of  and  a  little  internal  to  the  foramen  ovale 
is  the  foramen  rotundum.  This  is  the  commencement  of  a  short 
canal  which  passes  obliquely  forward  through  the  great  wing  of  the 
sphenoid  and  opens  into  the  spheno-maxillary  fossa  through  the 
upper  part  of  its  posterior  wall;  the  superior  maxillary  or  second 
division  of  the  fifth  nerve  passes  through  this  canal.  Toward  the 
front  of  the  middle  fossa  we  have  the  sphenoidal  fissure  opening 
into  the  orbit;  this  is  a  triangular  opening  between  the  free  border 
of  the  great  wing  and  the  under  surface  of  the  lesser  wing  of  the 
sphenoid,  its  base  being  inward  toward  the  body  of  the  sphenoid. 
Through  this  fissure  pass  the  third,  fourth,  and  the  ophthalmic  or 
third  division  of  the  fifth  nerve,  the  ophthalmic  vein,  etc. 


32 


HEAD  AKD  FACE. 


Fig.  14.— Base  of  Skull  from  Within.  C,  cavernous  sinus;  CG,  Casserian 
ganglion;  IP,  inferior  petrosal  sinus;  JF,  jugular  foramen;  L,  lateral  sinus; 
MA,  anterior  branch  of  middle  meningeal;  MP,  posterior  branch  of  middle 
meningeal;  SP,  superior  petrosal  sinus;  8,  sigmoid  (lateral)  sinus;  1,  first 
(ophthalmic)  division  of  fifth  nerve;  2,  second  (superior  maxillary)  division; 
3,  third  (inferior  maxillary)  division.  The  first  (ophthalmic)  division  rests 
upon  and  is  blended  with  the  wall  of  the  cavernous  sinus.  The  second  divis- 
ion lies  alongside  of,  but  is  not  connected  with,  the  wall  of  the  cavernous 
sinus. 


ANATOMY  OF  THE  MIDDLE  FOSSA.  33 

The  cavernous  sinus  is  a  wide,  loose,  thin-walled  canal,  situated 
between  the  layers  of  the  dura  mater.  It  reaches  from  the  apex  of 
the  petrous  portion  of  the  temporal  bone  behind  to  the  inner  end 
of  the  sphenoidal  fissure  in  front,  being  lodged  in  the  cavernous 
groove  upon  the  side  of  the  body  of  the  sphenoid.  The  lumen  of 
the  cavernous  sinus  presents  a  reticular  structure,  being  broken  up 
into  numerous  cellular  spaces  by  trabeculse  and  septa  which  pass  in 
various  directions.  Anteriorly,  it  receives  the  ophthalmic  vein,  and, 
posteriorly,  joins  both  petrosal  sinuses  and  communicates  with  the 
pterygoid  plexus  through  veins  which  enter  the  skull  through  the 
foramina  ovale,  spinosum,  and  lacerum  medium.  The  external  bor- 
der of  the  cavernous  sinus  corresponds  to  a  line  running  from  before 
backward,  which  would  skirt  the  inner  margin  of  the  foramen 
rotundum  (see  Fig.  14). 

The  internal  carotid  artery  enters  the  cranium  through  the 
foramen  lacerum  medium  and  passes  forward,  along  the  side  of  the 
body  of  the  sphenoid,  enveloped  by  the  cavernous  sinus,  the  sinus 
being,  as  it  were,  wrapped  entirely  around  the  artery.  (One  could 
not  wound  the  artery  in  this  situation  without  first  cutting  into  the 
sinus.)  Anteriorly,  at  the  inner  side  of  the  anterior  clinoid  process, 
the  internal  carotid,  after  giving  off  its  ophthalmic  branch,  turns 
upward  and,  passing  through  an  opening  in  the  dura  mater,  divides 
into  its  terminal  branches.  Along  the  outer  side  of  the  artery,  and 
therefore  also  inclosed  within  the  cavernous  sinus,  runs  the  sixth 
nerve.  In  the  outer  wall  of  the  cavernous  sinus  and  intimately 
united  to  it,  the  third,  the  fourth,  and  the  ophthalmic  or  first 
division  of  the  fifth  nerve  are  lodged;  these  structures  cannot  be 
separated  from  the  wall  of  the  sinus  without  tearing  it,  and  their 
relation  to  each  other  is  in  the  order  given  both  from  within  out- 
ward and  from  above  downward. 

The  fifth  nerve  at  its  origin  appears  upon  the  side  of  the  pons 
Varolii,  and  consists  of  a  thick  sensory  and  a  small  motor  root; 
these  pass  forward  through  an  oval  slit  in  the  dura  mater  and 
across  the  upper  border  of  the  petrous  portion  of  the  temporal 
bone,  near  its  apex,  into  the  middle  fossa  of  the  skull.  As  the 
roots  pass  over  the  upper  border  of  the  petrous  portion,  they  lie 
beneath  the  superior  petrosal  sinus.  In  its  course  the  nerve  lies 
outside  the  dura  mater,  extradural:  i.e.,  between  the  dura  mater 
and  the  base  of  the  skull.  Upon  reaching  the  front  surface  of  the 
petrous  portion  of  the  temporal  bone  the  sensory  root  presents  a 


34  HEAD  AND  FACE. 

swelling,  the  Casserian  ganglion.  The  motor  root  takes  no  part  in 
the  formation  of  this  ganglion,  but  lies  underneath  it.  The  ganglion 
is  reddish  gray;  crescentic  or  semilunar  in  shape;  its  anterior  convex 
border  looks  forward,  downward,  and  outward.  It  is  14  to  22  mm. 
wide,  4  mm.  from  before  backward,  and  1 1/2  mm.  in  thickness. 

Given  off  from  the  anterior  border  of  the  ganglion  are  the  three 
divisions  of  the  fifth  nerve.  Of  these,  the  first,  or  ophthalmic,  the 
longest  and  thinnest  of  the  three,  is  the  most  internal  and  passes 
from  behind  forward  and  upward  along,  or  rather  in,  the  outer  wall 
of  the  cavernous  sinus,  entering  the  orbit  through  the  sphenoidal 
fissure.  On  account  of  its  intimate  relation  to  the  wall  of  the  sinus, 
any  attempt  to  separate  it  would  tear  the  wall  of  the  sinus;  it  is 
in  close  relation  with  the  third  and  fourth  nerves,  the  carotid  artery, 
and  the  sixth  nerve.  The  second,  or  superior  maxillary,  division  lies 
external  to  the  preceding,  is  8  to  11  mm.  long,  and  passes  forward, 
entering  the  foramen  rotundum,  and  emerges  from  this  canal  in  the 
spheno-maxillary  fossa.  This  branch  lies  close  to  the  outer  edge 
of  the  cavernous  sinus,  but  is  not  joined  to  it,  and  may  be  readily 
removed  without  danger  to  the  sinus.  The  third,  or  inferior  maxil- 
lary, division,  the  most  external  of  the  three,  is  short  and  thick,  and 
passes  forward  and  outward,  leaving  the  skull  through  the  foramen 
ovale  in  company  with  the  motor  root.  The  motor  root  winds 
around  the  third  division  to  get  upon  its  outer  side,  the  two  be- 
coming joined  just  after  their  exit  through  the  foramen  ovale.  The 
ganglion  rests  in  the  depression  already  described  upon  the  front 
surface  of  the  petrous  portion  of  the  temporal  bone.  The  motor 
root  takes  no  part  in  the  formation  of  the  ganglion,  but  lies  beneath 
it,  between  it  and  the  bone.  At  times  the  bone  is  absent  in  this 
location  and  in  such  cases  the  ganglion  is  separated  from  the  carotid 
artery  only  by  the  fibrous  tissue  which  intervenes.  The  surface  of 
bone  upon  which  the  ganglion  and  its  three  divisions  rest  is  covered 
by  the  periosteum.  The  ganglion  and  its  divisions,  as  already  men- 
tioned, are  placed  extradural:  i.e.,  between  the  dura  mater  and  the 
base  of  the  skull;  the  dura  roofs  them  over,  and  is  attached  to  the 
margins  of  the  depression  in  which  the  ganglion  rests  and  to  the 
floor  of  the  middle  fossa  of  the  skull,  along  the  inner  margin  of 
the  second  division  and  along  the  outer  margin  of  the  third  division; 
so  that  not  only  the  ganglion,  but  its  second  and  third  divisions  as 
well,  are  thus  roofed  in.  This  space,  in  which  the  ganglion  and  its 
second  and  third  divisions  are  thus  inclosed,  is  called  the  cavum 


ANATOMY  OF  THE  MIDDLE  FOSSA.  35 

Meckelii.  Beyond  the  ganglion  and  its  divisions  the  dura  is,  as 
elsewhere,  closely  applied  to  the  surface  of  the  hone.  The  ganglion 
and  its  divisions  are  but  loosely  attached  to  the  periosteum  which 
covers  the  surface  of  the  hone  upon  which  they  rest  (floor  of  cavum 
Meckelii)  and  to  the  dura  mater  which  covers  them  and  forms  the 
roof  of  the  cavum  Meckelii. 

The  cavum  Meckelii  is  really  a  space  in  the  floor  of  the  middle 
fossa  of  the  skull  between  the  bone  and  the  non-attached  dura, 
which  lodges  the  ganglion  and  its  second  and  third  divisions. 

The  Casserian  ganglion  is  in  relation,  internally,  with  the 
carotid  artery  and  cavernous  sinus.  Behind  the  ganglion  is  the 
superior  petrosal  sinus  underneath  which  the  roots  of  the  nerve 


Fig.  15. — Transverse  Section  through  Floor  of  Middle  Fossa.  B,  bone  that 
forms  floor  of  middle  fossa;  CA,  internal  carotid  artery  inclosed  within  the 
trabeculated  cavernous  sinus;  CM,  cavum  Meckelii;  D,  dura  mater  lining 
floor  of  middle  fossa  and  roofing  over  cavum  Meckelii;  P,  dura  lining  floor  of 
cavum  Meckelii — periosteum;  3,  4,  51,  third,  fourth,  and  first  (ophthalmic) 
divisions  of  the  fifth  nerve,  lodged  in  the  wall  of  the  cavernous  sinus;  511, 
5m,  second  (superior  maxillary)  and  third  (inferior  maxillary)  divisions  of 
fifth  nerve,  situated  between  the  dura  and  base  of  the  skull  in  the  cavum 
Meckelii;  6,  sixth  nerve  inclosed  within  cavernous  sinus  close  to  the  outer 
side  of  the  internal  carotid. 


must  pass  in  order  to  join  the  ganglion  as  it  rests  upon  the  front 
surface  of  the  petrous  portion.  The  superior  petrosal  sinus  is  con- 
tained in  the  edge  of  the  tentorium  cerebelli,  which  is  attached  to 
the  superior  border  of  the  petrous  portion. 

The  middle  meningeal  artery  enters  the  skull  through  the 
foramen  spinosum  just  external  to  and  a  little  behind  the  foramen 
ovale  (through  which  the  third  division  passes  out  of  the  skull)  and 
would  therefore  be  met  with  in  approaching  these  structures  through 
an  opening  in  the  side  of  the  skull. 


36  HEAD  AND  FACE. 

Extirpation  of  the  Casserian  Ganglion  (Hartley-Krause) . — The 

patient  is  placed  in  a  semirecumbent  position  with  the  head  turned 
partly  to  one  side.  A  horeshoe-shaped  flap,  consisting  of  the  in- 
tegument and  the  underlying  muscle  and  the  corresponding  segment 
of  bone,  is  turned  back. 

The  incision  passes  through  the  whole  thickness  of  the  soft 
parts,  including  the  periosteum,  down  to  the  bone.  This  incision 
commences  anteriorly,  just  above  the  zygoma,  and  a  good  finger's 
breadth  behind  the  external  angular  process;  it  is  carried  upward 
upon  the  temporal  region,  describing  an  arc,  its  posterior  limb  ter- 
minating behind,  just  in  front  of  the  tragus.  Hemorrhage  should 
be  controlled  with  clamps.  The  flap  thus  marked  out  should  meas- 
ure in  its  vertical  diameter  three  inches,  about  two  inches  across  its 
widest  part,  and  from  one  and  one-half  to  two  inches  at  its  base, 
which  is  just  above  the  zygoma.  Corresponding  to  the  skin  incision 
a  groove  is  now  chiseled  all  around  in  the  bone;  this  groove  may  be 
commenced  with  a  circular  saw  and  completed  with  a  chisel.  The 
Hartley  chisels  are  probably  the  best  for  this  purpose,  as  they  cut 
a  distinct  groove;  if  an  ordinary  narrow  chisel  is  used,  it  should  be 
held  quite  obliquely  and  only  its  corner  engaged  in  the  bone  while 
cutting.  This  groove  should  be  deepened  to  the  same  extent 
throughout  its  whole  length,  going  over  it  several  times  before 
finally  penetrating  through  the  entire  thickness  of  the  bone.  The 
groove  should  reach  entirely  through  the  bone,  except  perhaps  at 
its  lowest  part,  down  near  the  zygoma.  Care  should  be  taken  not 
to  injure  the  dura  with  the  chisel. 

The  elevator  is  now  introduced  as  a  lever  into  the  upper  part 
of  the  groove,  and  with  a  prying  motion  the  segment  of  bone,  with 
the  soft  parts  attached,  is  broken  through  at  its  base  and  turned 
well  down  over  the  zygoma;  if  the  opening  is  not  sufficiently  large, 
one  may  cut  more  bone  away  from  the  lower  margin  of  the  opening 
with  the  bone  forceps.  It  is  well  if  the  section  through  the  bone 
is  so  made  that  its  edge  presents  a  somewhat  beveled  margin,  so 
that  it  may  fit  better  when  replaced  (see  Fig.  13).  Through  this 
opening  in  the  skull  the  dura  is  exposed,  the  anterior  branch  of  the 
middle  meningeal  ramifying  upon  it  toward  the  front;  at  times  this 
branch  is  torn  when  the  plate  of  bone  is  reflected,  especially  if  the 
groove  in  which  it  is  lodged  is  unusually  deep;  if  injured,  it  should 
be  clamped  and  tied.  Now,  with  the  fingers,  the  dura  is  separated 
from  the  bone:  floor  of  the  middle  fossa.    This  may  be  done  rapidly 


EXTIRPATION  OF  THE  CASSERIAN  GANGLION.  37 

until  the  middle  meningeal  artery,  as  it  enters  the  skull  through 
the  foramen  spinosum,  is  met.  One  should  then  stop  and  secure 
this  vessel  with  a  double  catgut  ligature  and  divide  it;  it  would  prob- 
ably answer  to  tie  singly  or  without  ligating  the  vessel,  to  plug  the 
foramen  spinosum  with  catgut,  and  then  divide  the  artery — its  distal 
anastomoses  are  not  free.  The  field  of  operation  should  be  kept 
clear  of  blood  with  pads  on  holders.  After  tying  the  middle  menin- 
geal and  still  working  inward,  but  rather  more  cautiously,  the  dura 
is  separated  from  the  base  of  the  skull  with  a  blunt  elevator  or  with 
a  small  gauze  pad  in  a  forceps,  at  the  same  time  lifting  the  brain 
away  from  the  base  of  the  skull  toward  the  vault.  This  is  best  accom- 
plished with  the  aid  of  a  narrow,  polished,  right-angle  retractor:  serves 
as  a  reflector  at  the  same  time.  A  pad  of  gauze  may  be  interposed 
between  it  and  the  brain;  the  hemorrhage  may  be  thus  somewhat 
diminished.  The  hemorrhage  caused  by  separating  the  dura  mater 
from  the  bone  is  sometimes  considerable.  It  may  be  controlled  by 
a  few  minutes'  pressure  or  by  shifting  or  withdrawing  the  retractor 
for  a  few  minutes  and  allowing  the  brain  to  drop  back  upon  the 
surface  of  the  bone.  Thus  gradually  working  inward  we  reach  the 
third  division  of  the  nerve,  which  may  be  seen  passing  out  of  the 
skull  through  the  foramen  ovale.  This  trunk  may  be  seized  with  a 
narrow  forceps  and  isolated  as  far  back  as  the  ganglion;  it  serves 
as  a  guide  to  the  ganglion.  "Without  cutting  this  trunk,  we  then 
work  a  little  farther  inward,  toward  the  middle  line,  until  we  meet 
the  second  division.  This  is  likewise  isolated  from  the  foramen 
rotundum  back  as  far  as  the  ganglion.  The  upper  surface  of  the 
ganglion  is  now  gradually  freed  from  the  dura.  While  the  ganglion 
is  being  isolated  the  brain  should  be  well  retracted:  lifted  away  from 
the  base  of  the  skull.  The  ganglion  can  be  separated  from  the  over- 
lying dura  with  a  blunt  periosteum  elevator;  one  may  seize  and  pull 
upon  the  third  division  and  use  this  as  a  guide  to  the  ganglion.  It 
may  be  necessary  to  cut  a  few  connective-tissue  bands,  between  the 
ganglion  and  the  dura,  with  the  scissors,  and  in  doing  this  one  may 
accidentally  cut  into  the  dura;  but  this  is  of  no  special  significance; 
there  may  escape  some  cerebro-spinal  fluid,  but,  according  to  Tiffany, 
this  is  rather  an  advantage.  There  may  be  hemorrhage  occasioned 
in  isolating  the  ganglion,  but  this  may  again  be  controlled  by  press- 
ure or  by  shifting  the  retractor  or  allowing  the  brain  to  drop  back 
in  place  upon  the  bone  temporarily.  The  ganglion  should  be  freed 
as  far  back  as  the  superior  border  of  the  petrous  portion,  so  that 


38  HEAD  AND  FACE. 

one  may  see  the  white  trunk  of  the  nerve  beyond  the  ganglion.  Care 
should  be  exercised  in  freeing  the  inner  part  of  the  ganglion,  on 
account  of  the  proximity  of  this  part  to  the  cavernous  sinus  and  the 
carotid  artery.  The  ganglion  may  be  separated  from  the  surface 
of  the  bone,  upon  which  it  rests,  with  the  periosteum  elevator.  At 
times  this  surface  of  bone  is  absent,  and  the  ganglion  is  then  sepa- 
rated from  the  artery,  as  it  lies  in  the  carotid  canal,  by  only  a  thin, 
cartilaginous  or  fibrous  layer;  therefore  one  should  avoid  any  rough- 
ness during  this  step  of  the  operation. 

The  ganglion,  being  finally  free  all  around,  is  seized  with  a 
long  artery  clamp,  and  in  doing  this  one  should  avoid  catching  the 
dura,  etc.,  at  the  same  time.  The  third  and  second  divisions  are 
then  cut,  either  with  the  scissors  or  with  a  tenotome  close  to  their 
foramina;  in  cutting  the  third  division,  the  motor  branch  of  the 
nerve  is  usually  divided  at  the  same  time  with  it.  One  should  make 
an  effort  to  avoid  cutting  the  motor  branch  as  the  third  division  is 
severed,  but  this  is  oftentimes  difficult  and  in  many  cases  its  divis- 
ion is  excusable.  When  the  third  division  is  cut  there  may  be  con- 
siderable venous  hemorrhage  from  the  small  meningeal  branch 
which  enters  the  skull  through  the  foramen  ovale;  this  can  be  con- 
trolled by  packing  or  by  shifting  the  retractor  and  by  allowing  the 
brain  to  drop  back  for  a  few  minutes  upon  the  base  of  the  skull. 

No  attempt  should  be  made  to  isolate  or  cut  the  first,  the  oph- 
thalmic, division  on  account  of  the  danger  of  doing  damage  to  the 
third  and  fourth  nerves  and  to  the  cavernous  sinus,  and,  besides, 
this  branch  is  readily  torn  away  when  the  ganglion  is  twisted  out. 

After  the  second  and  third  nerves  have  been  divided  the  gan- 
glion, in  the  grasp  of  a  long,  narrow  forceps,  is  slowly  twisted  free, 
tearing  it  away  from  the  first  division  and  usually  bringing  away 
with  it  a  portion  of  the  trunk  of  the  nerve  for  a  greater  or  less 
distance  beyond  the  ganglion.  Should  the  cavernous  sinus  be  torn, 
the  hemorrhage  is  profuse;  but  this  can  be  controlled  by  temporarily 
packing  and  allowing  the  brain  to  drop  back  into  place  upon  the 
base  of  the  skull. 

The  bone  is  finally  replaced  and  the  incision  in  the  soft  parts 
closed  with  suture.  It  is  well  to  introduce  a  strip  of  gauze  through 
the  posterior  part  of  the  opening  in  the  skull,  especially  if  there  is 
considerable  oozing,  for  the  purpose  of  drainage. 

This  operation  may  be  followed  by  ulcer  of  the  cornea  or  con- 
junctivitis, due  to  infection  or  the  entrance  of  dirt  which  is  not 


SURGICAL  ANATOMY  OF  THE  MASTOID  REGION.  39 

appreciated  on  account  of  the  loss  of  sensation  in  the  eye.  This  may 
he  avoided  by.  bandaging  the  eye  or  sealing  it  with  a  "watch-crystal. 
Ptosis,  paralysis  of  the  muscles  of  the  eye,  etc.,  may  occur  as  a 
result  of  injury  to  the  third,  fourth,  and  sixth  nerves.  One  may 
avoid  these  conditions  by  keeping  away  from  the  first  division  of  the 
fifth  nerve  and  the  immediately  adjacent  third,  fourth,  and  sixth 
nerves  during  the  course  of  the  operation. 


THE  MASTOID  REGION  AND  THE  EAR. 

The  mastoid  region  and  the  ear  are  intimately  associated  with 
each  other  clinically. 

The  Surgical  Anatomy  of  the  Mastoid  Region. — The  mastoid 
region  is  that  part  of  the  skull  which  corresponds  to  the  mastoid 
portion  of  the  temporal  bone. 

The  integument  of  this  region  is  thin  and  contains  very  little 
fat;  its  blood-supply  is  derived  from  the  posterior  auricular  artery, 
which  ascends  just  behind  the  ear.  The  occipital  artery  ascends 
beneath  the  sterno-mastoid  muscle  and  becomes  superficial  midway 
between  the  mastoid  process  and  the  external  occipital  protuberance, 
whence  it  is  continued  upward  upon  the  back  of  the  skull. 

The  surface  of  the  mastoid  is  uneven  and  perforated  by  a  num- 
ber of  small  vascular  openings.  At  the  back  part  of  the  mastoid 
portion,  at  or  just  in  front  of  the  suture  line  between  it  and  the 
occipital  bone,  there  is  an  opening,  the  mastoid  foramen.  Through 
this  a  small  vein  passes  into  the  lateral  sinus  and  a  small  arterial 
branch  from  the  occipital  artery  to  the  dura  mater. 

The  inner  surface  of  the  mastoid  portion  presents  a  wide  groove, 
curving  from  above  downward  with  the  convexity  forward;  this 
lodges  the  sigmoid  (lateral)  sinus.  This  groove  is  located  about  half 
an  inch  behind  the  posterior  border  of  the  external  auditory  meatus, 
and  presents  the  opening  of  the  mastoid  foramen. 

The  mastoid  portion  is  prolonged  below  in  a  teat-like  process 
which  varies  considerably  in  size.  It  is  said  to  be  larger  in  muscular 
subjects;  it  is  comparatively  small  in  the  child.  The  structure  of 
this  process  varies.  Its  cortex  may  be  thin  or  may  be  thick  and 
very  hard  like  ivory.  The  interior  may  be  cut  up  into  a  number  of 
cellular  recesses  lined  with  mucous  membrane  and  communicating 
with  each  other  and,  through  the  antrum,  with  the  middle  ear,  or  it 
may  be  composed  of  ordinary  spongy  bone,  or  it  may  be  very  dense 


40  HEAD  AND  FACE. 

and  hard,  resembling  ivory.  There  is  always  present,  however,  even 
in  the  newborn,  at  least  one  space,  the  antrum.  The  mastoid  antrum 
is  a  space,  varying  in  size  from  a  small  pea  to  a  small  bean,  which 
is  found  in  the  mastoid  process  just  behind  the  tympanic  cavity; 
these  two  spaces  communicate  with  each  other  through  an  opening 
in  the  upper  part  of  the  posterior  wall  of  the  tympanum.  The  roof 
of  the  antrum  is  formed  by  the  same  plate  of  bone  that  forms  the 
roof  of  the  tympanum.  The  antrum  is  lined  with  mucous  mem- 
brane, which  is  continuous  with  that  of  the  tympanum.  The  antrum 
is  practically  a  part  of  the  tympanic  cavity,  and  an  inflammatory 
process  originating  in  the  tympanum  may  readily  extend  and  involve 
the  antrum,  etc.  Externally  the  antrum  may  be  located  upon  a 
level  with  the  upper  margin  of  the  external  auditory  meatus  and 
between  5  and  10  mm.  (say,  one-fourth  inch)  behind  this  opening, 
and  is  usually  found  at  a  depth  of  from  12  to  18  mm.  beneath  the 
external  surface  of  the  bone.  In  very  young  children  the  antrum  is 
comparatively  large  and  very  close  to  the  surface  of  the  bone,  just 
behind  the  upper  margin  of  the  external  auditory  meatus. 

The  outer  margin  of  the  bony  portion  of  the  auditory  canal  is 
marked  above  and  behind  by  a  spine,  the  spina  supra  meatum;  this 
spine  is  readily  recognized  after  the  soft  parts  have  been  incised  and 
separated,  and  may  be  used  as  a  landmark  in  locating  the  antrum. 
The  antrum  lies  upon  the  same  level  as  the  spine,  but  about  one- 
fourth  inch  posterior  to  it. 

The  mastoid  process  is  usually  made  up  of  a  number  of  cellular 
spaces,  the  pneumatic  mastoid,  all  lined  with  mucous  membrane  and 
communicating  through  the  antrum  with  the  middle  ear  (tympanum); 
these  reach  to  the  tip  of  the  process  and  often  penetrate  beyond  the 
limits  of  the  mastoid  process  into  the  occipital  bone  or  zygomatic 
process  or  they  may  extend  backward  into  the  mastoid  portion  proper, 
pretty  close  to  the  groove  which  lodges  the  sigmoid  sinus,  so  that 
there  may  be  but  a  very  thin  shell  of  bone  separating  the  mastoid 
cells  from  the  sinus.  Mastoids  vary  in  different  people  and  upon 
opposite  sides  in  the  same  person  as  to  the  extent  to  which  these 
cells  are  developed.  They  begin  to  develop  early  in  life,  but  the 
age  differs  at  which  they  are  found  fully  developed.  From  five  years 
on  they  are  fairly  well  marked,  and  it  is  said  that  at  the  age  of 
fifteen  years  they  are  all  developed  down  to  the  tip  of  the  process. 
Some  say  that  they  do  not  reach  complete  development  until  a  few 
years  later.     Occasionally  the-  septa  may  undergo  a  process  of  rare- 


ANATOMY  OP  THE  EAR. 


41 


faction,  the  septa  gradually  disappearing  and  the  spaces  opening  into 
each  other  until  they  are  all  combined  in  one  large  space  represented 
by  the  antrum.  Instead  of  as  above  described,  the  structure  of  the 
bone  may  be  spongy  or  it  may  be  excessively  dense  and  without  spaces, 
resembling  ivory. 


Fig.  16.— Side  of  Skull.  A,  position  of  opening  in  skull  to  expose  the  ante- 
rior branch  of  the  middle  meningeal  (Vogt's  lines) ;  C,  position  of  opening  for 
cerebellar  abscess;  MA,  location  of  mastoid  antrum  (directly  in  front  of  circle 
MA  is  the  spina  supra  meatum) ;  P,  opening  to  expose  the  posterior  branch 
of  middle  meningeal;  R,  Reid's  base-line  continued  backward  to  external 
occipital  protuberance;  S,  dotted  lines  represent  course  of  lateral  (sigmoid) 
sinus;  TS,  opening  in  the  skull  for  abscess  of  the  temporo-sphenoidal  lobe. 


The  Anatomy  of  the  Ear.  —  Changes  that  occur  in  the  first 
visceral  cleft  result  in  the  formation  of  the  external  and  middle 
ear.  The  internal  ear,  labyrinth,  etc.,  are  formed  within  the  sub- 
stance of  the  petrous  portion  of  the  temporal  bone.  The  external 
fossa,  or  cleft,  develops  into  the  external  auditory  canal  and  auricle; 


42  HEAD  AND  FACE. 

the  internal  fossa,  or  cleft,  which  opens  into  the  pharynx,  "becomes 
the  Eustachian  tube  and  tympanum.  Where  the  funduses  of  these 
clefts,  or  fossse,  meet,  their  walls  coalesce  and  thus  form  the  drum, 
the  partition  between  the  external  and  the  middle  ear.  The  margin 
of  the  outer  opening  of  the  external  cleft,  or  fossa,  becomes  thick- 
ened and  nodulated,  and  these  nodules,  coalescing,  form  the  external 
ear. 

The  hearing  apparatus  may  be  divided  into  the  external  ear, 
which  includes  the  auricle,  external  auditory  canal,  and  drum;  the 
middle  ear,  tympanum,  which  communicates  with  the  pharynx 
through  the  Eustachian  tube;  and  the  internal  ear,  labryinth,  etc., 
inclosed  within  the  petrous  portion  of  the  temporal  bone. 

The  auricle  is  made  up  of  a  cartilaginous  plate  considerably 
folded  upon  itself  and  covered  with  skin;  it  consists  of  several  parts. 
It  is  attached  to  the  side  of  the  head  by  ligamentous  bands;  one 
of  these  passes  forward  to  the  root  of  the  zygoma;  the  other  back- 
ward to  the  mastoid  process.  Its  blood-supply  is  derived  from 
branches  which  are  given  off  by  the  temporal  artery  in  front  and 
the  posterior  auricular  behind.  The  supply  is  very  abundant,  and 
therefore  wounds  of  the  ear  heal  kindly. 

The  external  auditory  canal  is  about  one  inch  (24  mm.,  Trolsch) 
in  length;  its  outer  portion,  comprising  one-third  of  its  length,  is 
cartilaginous  and  continuous  with  the  auricle;  the  inner  part,  com- 
prising two-thirds  of  its  length,  is  bone.  The  course  of  the  canal 
is  transverse,  but  it  suffers  two  curves:  one,  in  its  cartilaginous  part, 
with  its  convexity  forward;  the  second  at  the  junction  of  the  carti- 
laginous and  bony  parts,  with  its  convexity  backward;  this  junction 
is  the  narrowest  part  of  the  canal,  and  is  called  the  isthmus. 

To  expose  the  drum,  the  auricle  is  drawn  upward,  backward,  and 
outward  away  from  the  side  of  the  head. 

In  the  newborn  child  there  is  no  bony  portion  to  the  external 
auditory  canal,  this  part  being  represented  only  by  a  ring  of  bone 
into  which  the  drum  is  fitted.  This  bony  ring,  the  auditory  process,, 
is  incomplete,  and  is  applied  against  the  depressed,  hollowed-out 
under  surface  of  the  squamous  portion  of  the  temporal,  which  thus 
completes  the  ring.  At  this  early  age  the  drum  is  very  near  the  sur- 
face of  the  body,  there  being  no  depth  to  the  bony  auditory  canal. 
As  the  child  grows,  the  bony  ring,  the  auditory  process,  broadens  out, 
and  in  the  adult  is  represented  by  the  external  auditory  process, 
which  corresponds  to  its  outer  edge,  and  by  the  vaginal  process,  this 


ANATOMY  OF  THE  EAR.  43 

latter  forming  the  lower  and  anterior  wall  of  the  bony  portion  of  the 
auditory  canal  and  the  back  part  of  the  floor  of  the  glenoid  cavity. 
The  upper  wall  of  the  auditory  canal  is  formed  by  the  grooved  under 
surface  of  the  squamous  portion  of  the  temporal  bone.  The  outer 
edge  of  the  auditory  process  is  rough,  and  to  it  is  attached,  by  firm 
connective  tissue,  the  cartilaginous  part  of  the  auditory  canal. 

The  skin  which  lines  the  interior  of  the  auditory  canal  is  con- 
tinuous with  that  which  covers  the  surface  of  the  drum. 

The  bony  part  of  the  external  auditory  canal  is  in  relation, 
above,  with  the  middle  fossa  of  the  skull,  from  which  it  is  separated 
by  a  thin,  cellular  plate  of  bone,  part  of  the  squamous  portion  of 
the  temporal;  behind,  it  is  in  relation  with  the  mastoid  system  of 
cells,  and,  in  front,  with  the  condyle  of  the  lower  jaw  and  the  parotid 
gland. 

Blows  upon  the  chin  may  be  transmitted  through  the  lower  jaw 
to  the  condyle,  and  in  this  way  may  injure  the  auditory  canal,  so  that 
there  may  be  an  issue  of  blood  from  the  external  auditory  meatus. 
Purulent  processes  involving  the  auditory  canal  may  present  cere- 
bral complications,  especially  in  children,  without  the  middle  ear 
being  involved,  the  infection  in  these  cases  passing  through  the  roof 
of  the  auditory  canal  directly  into  the  cavity  of  the  skull. 

The  drum  is  the  septum  between  the  external  and  the  middle 
ears.  It  is  made  up  of  skin  externally,  and,  internally,  of  the  mu- 
cous membrane  of  the  tympanum;  interposed  between  those  two  is 
a  layer  of  connective  tissue.  The  drum  is  set  in  a  bony  ring,  and 
forms  the  greater  part  of  the  external  wall  of  the  tympanum.  It  is 
set  obliquely  and  in  such  a  way  that  its  outer  surface  looks  down- 
ward, forward,  and  outward;  the  anterior  wall  of  the  external  audi- 
tory canal  is  thus  longer  than  the  upper,  posterior  wall. 

The  middle  ear  consists  of  the  tympanum  and  adjoining  air- 
cells  and  the  Eustachian  tube. 

The  tympanum  is  a  wedge-shaped  cavity  separated  from  the 
external  auditory  canal  by  the  drum  and  communicating  by  an 
opening  in  its  anterior  end,  through  the  Eustachian  tube,  with  the 
pharynx.  In  the  anterior  part  is  also  seen  the  Glaserian  fissure, 
through  which  the  middle  ear  communicates  with  the  glenoid  cavity 
and  through  which  the  chorda  tympani  leaves  the  tympanum. 

The  carotid  artery,  surrounded  by  a  venous  plexus,  traverses  a 
canal,  in  the  temporal  bone,  which  is  located  just  in  front  of  the 
tympanum  and  which  is  separated  from  this  cavity  by  a  very  thin 


44  HEAD  AND  FACE. 

plate  of  bone  that  is,  at  times,  perforated.  Behind,  the  tympanum 
communicates  with  the  mastoid  antrum  through  an  opening  in  the 
upper  part  of  its  posterior  wall.  The  inner  wall  of  the  tympanum, 
that  opposite  the  drum,  presents,  toward  the  front,  the  promontory; 
behind  this,  two  openings,  one  above,  the  foramen  ovale,  and  an- 
other below  and  a  little  behind,  the  foramen  rotundum.  The  laby- 
rinth is  located  beneath  this  inner  wall,  in  the  petrous  portion  of 
the  temporal  bone.  This  inner  wall  presents  a  smooth,  curved  ridge 
above  the  foramen  ovale  which  runs  backward  and  downward  toward 
the  back  of  the  tympanum;  it  corresponds  to  the  position  of  the 
Fallopian  canal  which  lodges  the  facial  nerve  in  its  course  through 
the  petrous  portion  of  the  temporal  bone.  The  layer  of  bone  which 
separates  the  nerve  from  the  cavity  of  the  tympanum  is  sometimes  very 
thin  or  perforated.  The  tympanum  communicates  with  the  posterior 
fossa  of  the  skull  through  the  labyrinth  and  the  internal  auditory 
canal,  which  is  traversed  by  the  facial  and  auditory  nerves.  The  bulb 
of  the  jugular  vein  is  lodged  in  the  depression  in  the  temporal  bone 
beneath  the  floor  of  the  tympanum.  The  layer  of  bone  which  forms 
the  floor  of  the  tympanum  is  usually  comparatively  thick,  though  it 
may  be  very  thin,  perforated,  or  entirely  absent.  In  the  latter  case 
the  mucous  membrane  lining  the  floor  of  the  tympanum  and  the  wall 
of  the  internal  jugular  vein  would  be  in  direct  contact  with  each  other. 
Through  small  openings  in  the  floor  of  the  tympanum,  Jacobson's 
nerve,  a  branch  from  the  glosso-pharyngeal,  and  some  small  arterial 
and  venous  branches  enter  the  tympanum. 

The  roof  of  the  tympanum,  the  most  common  link  between  dis- 
ease of  the  ear  and  intracranial  complications,  is  a  thin,  cellular 
plate  of  bone;  it  may  be  very  thin,  perforated,  or  entirely  absent. 
This  plate  of  bone  reaches  from  the  petrous  portion  of  the  temporal 
bone  over  to  the  inner  surface  of  the  squamous  portion,  where  a 
suture  line,  petroso-squanious,  exists.  In  the  child  this  suture  line 
is  open  and  contains  a  process  of  dura  mater  which  joins  with  the 
mucous  membrane  lining  of  the  tympanum  and  carries  blood-vessels 
which  take  part  in  the  supply  of  both  these  membranes.  This  con- 
dition, although  not  so  visible,  continues  to  exist  in  the  adult.  This 
same  thin  layer  of  bone,  which  forms  the  roof  of  the  tympanum, 
reaches  backward  and  forms  also  the  roof  of  the  mastoid  antrum. 
The  roof  of  the  tympanum  and  antrum  forms  part  of  the  floor  of 
the  middle  fossa  of  the  skull,  and  is  in  relation  with  the  dura  mater, 
etc.,  and  with  the  temporo-sphenoidal  lobe  of  the  brain. 


ANATOMY  OF  THE  EAR.  45 

The  course  of  the  facial  nerve  through  the  temporal  bone  and 
its  relation  tp  the  tympanum  and  the  mastoid  antrum  are  impor- 
tant. The  nerve  enters  the  internal  auditory  canal  in  company  with 
the  auditory  nerve,  and  passes  in  a  direction  forward  and  outward, 
reaching  the  inner  wall  of  the  middle  ear,  tympanum,  just  above 
the  foramen  ovale;  here  it  makes  a  turn  and  runs  backward  and 
downward  in  the  aqueductus  Fallopii.  The  course  of  this  canal  is 
indicated  by  a  prominent  linear  elevation  upon  the  inner  wall  of 
the  tympanum  just  above  the  foramen  ovale;  at  the  back  of  the 
tympanum,  the  nerve,  as  it  curves  downward  and  still  contained 
within  the  aqueductus  Fallopii,  is  situated  but  a  short  distance  in 
front  of  the  antrum.  It  continues  its  course  through  the  substance 
of  the  petrous  portion  of  the  temporal  bone,  emerging,  externally, 
upon  the  base  of  the  skull,  through  the  stylo-mastoid  foramen.  This 
foramen  is  located  internal  to,  and  a  little  in  front  of,  the  base  of 
the  mastoid  process.  Just  before  the  facial  nerve  emerges  from  the 
stylo-mastoid  foramen  and  while  still  contained  within  the  canal,  it 
gives  off  a  branch,  the  chorda  tympani,  which  passes  forward  and 
upward  through  a  separate  canal  in  the  petrous  portion,  and  enters 
the  tympanum  through  an  opening  in  its  posterior  wall,  near  the 
drum;  it  runs  forward  through  the  tympanic  cavity,  being  covered 
by  mucous  membrane,  and  escapes  through  the  Glaserian  fissure,  a  slit 
in  the  anterior  part  of  the  floor  of  the  tympanum,  into  the  glenoid 
cavity. 

The  stylo-mastoid  artery,  derived  from  the  posterior  auricular, 
enters  the  stylo-mastoid  foramen  to  supply  the  facial  nerve  and  also 
the  mucous  membrane  of  the  tympanum. 

The  Eustachian  tube  reaches  from  the  tympanum  to  the  phar- 
ynx; its  outer  one-third  is  bony;  its  inner  two-thirds,  cartilaginous. 
Where  these  join,  the  tube  is  narrowest:  the  isthmus.  The  tube 
opens  into  the  anterior  end  of  the  tympanum,  near  the  drum;  its 
inner  end  opens  into  the  pharynx  above  the  soft  palate  and  just 
behind  the  posterior  border  of  the  inferior  turbinated  bone.  The 
walls  of  the  cartilaginous  portion  of  the  tube  are  usually  in  contact 
and  the  tube  is  thus  closed.  To  ventilate  the  tympanum,  muscular 
action,  which  will  open  the  pharyngeal  end  of  the  tube,  is  required. 
This  is  accomplished  by  the  muscles  of  the  soft  palate:  the  tensor 
and  the  levator  palati. 


46  HEAD  AND  FACE. 

OPERATIONS  UPON  THE  MASTOID,  ETC. 

Wilde's  Incision. — This  consists  of  a  simple  incision  through 
the  soft  parts,  including  the  periosteum,  down  to  the  hone.  It  is 
placed  1  cm.  hehind  and  parallel  with  the  auricle,  and  reaches  from 
the  hase  of  the  mastoid  process  to  its  apex.  Usually  no  vessels  are 
cut  and  it  is  not  necessary  to  apply  any  ligatures.  It  is  often  suffi- 
cient in  very  young  children. 

Drilling  into  the  Antrum. — An  incision  is  made  through  the 
soft  parts  down  to  the  hone,  as  in  the  preceding  operation,  and  a 
channel  drilled  through  the  hone  down  into  the  antrum.  The  drill 
is  placed  upon  the  mastoid,  upon  a  level  with  the  upper  margin  of 
the  external  auditory  meatus,  spina  supra  meatum,  and  rather  less 
than  one-half  inch  posterior  to  it,  and  a  canal  is  then  drilled  through 
the  hone  in  a  direction  downward,  forward,  and  inward  toward  the 
antrum;  this  canal  should  not  be  carried  much  deeper  than  one-half 
inch.  This  operation  is  not  one  to  be  recommended,  as  it  is  uncer- 
tain and  may  be  dangerous,  especially  if  one  proceeds  deeper  than 
one-half  inch.  It  is  much  more  satisfactory  to  make  a  free  opening 
into  the  antrum  with  the  chisel. 

To  Open  into  and  Drain  the  Antrum. — The  patient  is  placed 
with  the  head  upon  the  side  resting  upon  a  thin  sand-bag. 

Eegardless  of  any  condition  that  may  complicate  mastoid  dis- 
ease, the  first  step  should  always  consist  in  opening  into  the  antrum. 
(Bacon,  Schwartz.) 

An  incision  is  made  1  cm.  (Schwartz) — one-third  inch — behind 
the  attachment  of  the  auricle,  through  the  soft  parts,  including  the 
periosteum,  down  to  the  surface  of  the  bone,  and  reaching  from  the 
base  of  the  mastoid  to  its  tip.  In  this  incision  we  do  not  meet 
the  posterior  auricular  artery,  and,  as  a  rule,  no  vessels  that  require 
ligation  are  divided.  With  the  elevator  the  soft  parts,  including  the 
periosteum,  are  then  separated  from  the  surface  of  the  bone,  expos- 
ing an  area  as  large  as  a  five-cent  piece  upon  a  level  with  and  just 
behind  the  external  auditory  meatus.  The  soft  parts  are  retracted 
with  broad,  sharp  retractors.  The  surface  of  bone,  which  is  thus 
laid  bare,  may  be  soft,  discolored,  and  may  further  present  the 
orifice  of  a  fistula,  or  it  may  be  firm  and  apparently  healthy  or  thick- 
ened, sclerosed,  and  ivory-like.  If  the  first  condition  exists, — that 
is,  if  the  bone  is  softened,  carious,  etc., — one  may  easily  gouge  it 
away  with  a  strong,  sharp  scoop,  continuing  thus  until  the  antrum 
is  reached.     With  the  curette  one  should  remove  all  the  bone  that 


OPERATIONS  UPON  THE  MASTOID,  ETC.  47 

is  apparently  diseased,  taking  away  enough  of  the  cortex,  especially 
down  toward  the  tip,  to  allow  good  drainage.  A  rongeur  forceps 
will  often  he  found  useful  in  thus  removing  the  cortex.  One  should 
watch  for  loose  pieces  of  carious  bone.  In  working  backward  toward 
the  sigmoid  sinus  one  should  be  careful  not,  inadvertently,  to  perfo- 
rate the  dura  and  enter  this  channel.  If  the  sinus  is  simply  exposed, 
this  is  of  no  special  significance.  There  may  be  some  hemorrhage 
from  emissary  veins  that  pass  through  the  mastoid  foramen  into  the 
sigmoid  sinus.  Fistulas  that  are  present  should  be  carefully  fol- 
lowed, thoroughly  curetted,  and  laid  open.  They  may  lead  into  the 
auditory  canal  or  into  the  cranial  cavity.  During  the  operation  one 
should  take  frequent  soundings  with  a  blunt  probe. 

If  the  surface  of  bone  which  is  exposed  is  not  softened  and  ap- 
parently healthy  and  we  may  select  a  point  at  which  to  commence 
the  excavation  in  the  bone,  we  choose  a  point  upon  a  level  with  the 
upper  border  of  the  external  auditory  meatus  (spina  supra  meatum) 
and  from  5  to  10  mm.  behind  it.  The  antrum  is  situated  about  one- 
fourth  inch  behind  the  anterior  border  of  the  mastoid  process  upon 
a  level  with  the  upper  border  of  the  external  auditory  canal.  In 
cutting  through  the  bone  into  the  antrum  we  commence  by  using 
a  broad  chisel, — they  vary  in  width  from  2  to  8  mm., — working 
rather  with  the  corner  of  its  edge  and  chipping  the  bone  out  in  the 
form  of  a  circle  at  least  three-fourths  inch  in  diameter.  This  ex- 
cavation is  carried  deeper  into  the  substance  of  the  bone,  in  a  direc- 
tion forward,  inward,  and  downward.  As  we  progress,  narrower 
chisels  or  gouges  may  be  used  and  the  opening  made  smaller  in 
diameter.  We  continue  thus,  occasionally  sounding  with  the  probe, 
until  the  antrum  is  reached.  It  may  contain  only  a  few  drops  of 
pus.  During  this  part  of  the  operation  the  field  may  be  kept  clear 
of  blood  and  chips  of  bone  by  a  stream  of  salt-water  or  bichloride 
or  by  sponging.  A  funnel-shaped  excavation,  extending  through  the 
substance  of  the  mastoid,  is  thus  made,  the  base  of  the  opening  corre- 
sponding to  the  external  surface  of  the  bone  and  its  narrow  end  to 
the  antrum.  The  base,  or  external  orifice,  of  this  canal  should  be 
sufficiently  large  to  allow  of  convenient  work  in  its  deeper  part.  The 
antrum  is  usually  found  at  a  depth  of  from  12  to  20  mm.,  but  may 
occasionally  be  nearer  the  surface.  After  having  opened  into  the  an- 
trum, if  a  probe  introduced  feels  firm,  healthy  bone  and  if  no  sinuses 
are  present,  one  may  then  proceed  to  complete  the  operation  by  goug- 
ing away  the  cortex  down  to  the  tip  of  the  process,  in  order  to  expose 


48  HEAD  AND  FACE. 

and  drain  these  most  dependent  cells.  One  should  also  see  that  the 
communication  between  the  antrum  and  the  tympanum  is  free.  The 
drum  is  usually  already  perforated,  and  fluid  introduced  into  the 
antrum  may  escape  in  part  from  the  ear.  After  irrigating,  a  thin 
strip  of  gauze  is  packed  into  the  opening  in  the  mastoid,  reaching 
into  the  antrum,  and  the  edges  of  the  soft  parts  drawn  together 
in  part.  This  would  be  the  procedure  in  a  simple  uncomplicated 
ease  of  mastoid  disease. 

In  order  to  avoid  accidental  opening  into  the  sigmoid  sinus, 
the  base,  the  commencement  of  the  cone-shaped  canal  which  is 
chiseled  through  the  bone  into  the  antrum,  is  placed  anterior  to  the 
location  of  the  sinus;  and  as  we  proceed  deeper  into  the  substance 
of  the  bone  we  work  in  a  direction  forward,  downward,  and  inward, 
so  that  there  is  no  danger  of  injuring  the  sinus,  as  it  lies  behind  the 
most  posterior  part,  base,  of  this  excavation  in  the  bone;  and  as  we 
proceed  deeper  into  the  substance  of  the  bone  we  get  farther  away 
from  the  sinus.  It  is  of  but  little  consequence  if  the  sinus  is  ex- 
posed, but  one  should  avoid  accidentally  perforating  the  dura  and 
wounding  it.  If  the  sinus  is  opened,  the  hemorrhage  which  results 
may  be  controlled  by  the  pressure  of  an  aseptic  tampon;  air  may 
be  sucked  into  the  sinus,  if  it  is  opened,  but  this  is  not  accompanied 
by  any  danger  (Schwartz).  Accidental  opening  into  the  middle 
fossa  of  the  skull  is  avoided  by  commencing  the  channel  in  the  bone 
below  tbe  level  of  the  upper  margin  of  the  external  auditory  meatus, 
below  the  spina  supra  meatum,  and,  as  we  proceed,  working  in  a 
direction  rather  downward.  The  floor  of  the  middle  fossa  will  thus 
lie  above  the  base  of  the  cone-shaped  canal  which  is  made  in  the 
bone. 

If  one  does  not  chisel  beyond  the  antrum,  there  is  but  little 
danger  of  injuring  the  facial  nerve  or  the  inner  wall  of  the  tym- 
panum (labyrinth).  The  facial  nerve,  contained  within  the  Fallo- 
pian tube,  lies  rather  deeper  than  the  antrum  and  anterior  to  it, 
in  the  inner  wall  of  the  tympanum.  If  one  penetrates  to  a  depth 
of  2  cm.  or  more,  there  is  then  danger  of  getting  beyond  the  antrum 
and  injuring  the  facial  nerve  or  the  labyrinth. 

For  Thrombosis  of  the  Sigmoid  Sinus. — The  sigmoid  sinus  is 
encountered  about  one-half  to  three-fourths  inch  posterior  to  the 
bony  auditory  canal  (spina  supra  meatum). 

One  should  always,  as  a  preliminary  step,  open  into  the  antrum 
as  described  above  and  from  here  start  out  to  investigate  the  sinus, 


OPERATIONS  UPON  THE  MASTOID,  ETC.  49 

etc.  After  the  antrum  has  been  opened  an  incision  is  carried  back- 
ward, through  the  soft  parts,  for  a  distance  of  about  two  inches, 
and  with  the  "chisel  or  rongeur  the  bone  is  removed  in  a  direction 
backward  until  the  region  of  the  sinus  is  reached  and  the  dura  ex- 
posed. The  opening  in  the  skull  may  be  still  farther  enlarged  by 
cutting  away  its  margin  with  the  rongeur  forceps,  so  that  the  sinus 
is  freely  exposed,  and  an  opening  made  in  the  skull  which  is  suffi- 
ciently large  to  work  through.  This  opening  in  the  skull  should 
be  at  least  as  large  as  a  silver  quarter.  Oftentimes  pus  and  granula- 
tion tissue  are  met  with  just  as  soon  as  the  dura  is  exposed, — extra- 
dural abscess, — and  if  the  sinus  is  not  diseased  it  will  not  be  neces- 
sary to  proceed  farther,  it  being  sufficient  to  curette  and  drain  the 
parts  about  the  sinus  without  opening  into  the  latter. 

If  the  sinus  is  thrombosed,  it  will  appear  firm  and  prominent, 
and  in  case  of  doubt  an  aseptic  aspirating  needle  may  be  introduced. 
If  pus  is  not  present  in  the  sinus  and  the  needle  withdraws  fluid 
blood  it  does  not  necessarily  prove  that  the  sinus  is  unaffected. 
Tenderness  along  the  course  of  the  internal  jugular,  etc.,  is  an  indi- 
cation for  opening  the  sinus.  If  in  doubt  it  is  always  wise  to  incise 
the  sinus,  as  this  is  not  accompanied  by  any  special  danger. 

If  one  decides  to  open  the  sinus  it  should  be  done  by  making 
an  incision,  corresponding  to  its  long  diameter,  with  a  sharp,  narrow- 
bladed  knife.  If  a  clot  is  found,  this  should  be  curetted  away  first 
from  the  jugular  end  down  to  the  bulb, — if  necessary,  removing  more 
bone  with  the  rongeur, — until  there  is  a  free  flow  of  blood:  good, 
free  bleeding  tends  to  wash  out  any  remaining  portions  of  clot.  This 
bleeding  may  be  readily  controlled  by  introducing  a  small  wad  of 
gauze  between  the  sinus  and  the  adjoining  bone.  This  flow  of  blood 
does  not  necessarily  prove  that  there  is  not  a  clot  in  the  jugular 
vein  beyond  the  bulb:  blood  may  flow  around  from  the  inferior 
petrosal  sinus. 

This  procedure  is  repeated  in  the  other  direction — i.e.,  toward 
the  torcular — until  hemorrhage  is  established;  this  may  then  be 
-controlled  in  a  similar  manner.  It  may  be  well,  after  the  hemor- 
rhage has  been  controlled,  to  remove  the  packing  and  freely  irrigate 
the  sinus  with  normal  salt  solution.  Before  opening  the  sinus,  the 
internal  jugular  vein,  the  facial  vein,  etc.,  may  be  exposed  in  the 
neck  and  tied,  or  the  internal  jugular,  in  its  entirety,  and  including 
all  its  branches,  may  be  resected  through  an  incision  in  the  neck 
after  first  having  tied  the  vessel  below,  at  the  clavicle,  and  above, 


50  HEAD  AND  FACE. 

at  the  bulb  (avoid  the  pneumogastric  nerve).  This  procedure  is 
indicated  especially  if  tenderness  and  induration  are  present  along 
the  course  of  the  internal  jugular  vein:  along  the  anterior  border 
of  the  sterno-mastoid  muscle  (McKernon).  If  the  internal  jugular 
vein  has  not  been  tied,  it  may  be  compressed  in  the  neck,  during  the 
operation,  to  prevent  the  passage  of  dislodged  clots  (Dench). 

Besides  the  condition  described,  we  may  find  an  opening  lead- 
ing through  the  dura  mater  to  a  collection  of  pus  beneath  the  dura 
or  within  the  cerebellum;  these  purulent  collections  may  also  be 
present  without  thrombosis  of  the  sinus  or  without  a  fistulous  open- 
ing in  the  dura.  All  fistulous  openings  should  be  thoroughly  explored 
and  treated  as  the  condition  indicates. 

For  Cerebellar  Abscess. — The  opening  in  the  skull  may  be  made 
with  a  trephine  or  chisel.  Usually  the  antrum  and  sinus  have  al- 
ready been  explored,  and  the  opening  in  this  case  may  be  simply 
extended  backward  with  the  rongeur.  The  center  of  the  opening 
in  the  skull  for  cerebellar  abscess  should  be  located  two  inches  behind 
the  external  auditory  meatus,  and  should  be  placed  below  a  line 
drawn  from  the  upper  margin  of  the  external  auditory  meatus  to 
the  occipital  protuberance  (see  Fig.  16).  The  opening  in  the  bone 
is  thus  placed  below  the  superior  curved  line  of  the  occipital  bone 
and  we  enter  therefore  below  the  attachment  of  the  tentorium  cere- 
belli  and  below  the  course  of  the  lateral  sinus.  The  bone  is  here 
very  thin,  and  the  opening  may  be  readily  enlarged  to  any  necessary 
extent  with  the  rongeur.  A  good  free  opening  should  be  made  in 
the  skull.  One  may  meet  pus  between  the  dura  mater  and  the  bone 
or  there  may  be  a  fistulous  opening  in  the  dura  leading  to  a  deeper 
purulent  collection.  If  there  is  no  opening  in  the  dura  an  aspirating 
needle  may  be  introduced  and  search  thus  made  for  the  pus.  When 
the  pus  is  located,  without  withdrawing  the  needle,  the  dura  may  be 
incised  and  a  director  or  thin  artery  forceps  introduced  along  the 
aspirating  needle  and  the  opening  then  enlarged  by  spreading  the 
forceps  so  as  to  permit  the  introduction  of  the  little  finger.  The 
abscess  cavity  may  be  irrigated  with  a  double-current  tube  and  then 
loosely  packed.    The  opening  in  the  dura  may  be  closed  in  part. 

For  Extradural  Abscess  in  the  Middle  Fossa. — There  may  be  an 
abscess  located  between  the  dura  mater  and  the  bone. 

If  the  mastoid  antrum  has  already  been  explored  one  may  find 
a  fistula  leading  through  the  roof  of  the  antrum  or  tympanum  into 
the  middle  fossa.    The  incision,  which  is  already  present  and  through 


SURGICAL  ANATOMY  OF  THE  FACE.  51 

which  the  mastoid  antrum  has  been  opened,  is  prolonged  from  the 
base  of  the  mastoid  in  a  direction  upward  and  forward  over  the  ear, 
dividing  the  temporal  vessels  and  muscle.  With  the  rongeur  or 
chisel,  the  bone  is  cut  away  so  that  one  may  enter  the  middle  fossa 
just  above  and  in  front  of  the  external  auditory  meatus;  here  we 
work  in  between  the  tegmen  tympani  and  the  dura  mater,  where 
the  abscess  is  usually  located.  The  pus  is  evacuated  and  the  abscess 
cavity  drained  as  described  in  the  preceding  operation. 

For  Temporo-sphenoidal  Abscess.  —  Associated  with  the  extra- 
dural abscess  we  may  find  an  abscess  in  the  temporo-sphenoidal  lobe, 
and  there  may  be  a  fistula  leading  through  the  dura  and  commu- 
nicating with  such  a  collection.  In  this  case  the  fistula  should  be 
followed,  enlarging  the  opening  in  the  dura,  evacuating  and  draining 
the  abscess.  A  temporo-sphenoidal  abscess  may  be  present  without 
an  extradural  abscess. 

If  the  mastoid  has  been  already  explored,  one  may  extend  the 
incision  upward  and  forward  over  the  ear,  as  described  in  the  pre- 
ceding operation,  and  remove  sufficient  bone  with  the  chisel  and 
rongeur,  proceeding  from  the  opening  in  the  mastoid,  or,  instead 
of  this,  a  button  of  bone  may  be  removed  with  the  trephine.  This 
opening  in  the  skull  should  be  at  least  one  inch  in  diameter  with 
its  center  located  one  and  one-fourth  inches  above  the  bony  meatus, 
and  may  be  farther  enlarged  with  the  rongeur  forceps  to  the  requisite 
dimensions  (see  Fig.  16). 

The  temporo-sphenoidal  lobe  may  also  be  exposed  by  doing 
a  temporary  resection  of  the  skull  (see  "Ligation  of  the  Middle 
Meningeal  Artery"). 

After  the  dura  has  been  exposed  an  aspirator  is  introduced,  and 
when  pus  is  discovered  the  dura  is  incised  and,  without  withdrawing 
the  needle,  a  director — or,  better,  an  artery  forceps — is  introduced 
and  the  abscess  freely  opened  by  spreading  the  forceps  and  with- 
drawing them.  The  finger  may  be  then  introduced  and  the  abscess 
cavity  irrigated  with  a  double-current  tube  and  packed.  The  open- 
ing in  the  dura  may  be  partly  closed. 

THE  FACE. 

Surgical  Anatomy  of  the  Face. — The  skin  of  the  face  is  soft, 
thin,  and  intimately  united  to  the  underlying  muscles  and  connective 
tissue,  and  cannot  be  pinched  up  without  including  these  deeper 


52  HEAD  AND  FACE. 

layers.  The  subcutaneous  tissue  of  the  face  is  widely  meshed,  and 
within  these  meshes  there  is  contained  much  fat.  Those  parts  of 
the  face  where  the  fat  is  absent  from  the  subcutaneous  layer  are 
loose  and  flaccid, — for  example,  under  the  eyes, — and  become  marked 
early  in  life  by  wrinkles.  These  parts  also  readily  become  swollen 
and  distended  in  dropsical  conditions.  In  this  layer  are  contained 
the  muscles  of  expression  and  the  vessels  and  nerves. 

The  facial  artery  is  the  chief  source  of  supply  to  the  face.  It 
is  a  large  vessel  derived  from  the  external  carotid.  It  pursues  a 
tortuous  course,  upward  and  forward,  across  the  side  of  the  face, 
from  the  anterior  border  of  the  masseter  to  the  angle  of  the  mouth, 
and  then,  as  the  angular,  continues  upward  alongside  the  nose,  anas- 
tomosing at  the  inner  canthus  with  a  branch  of  the  ophthalmic. 
Just  below  1  he  corner  of  the  mouth  the  facial  gives  off  a  branch,  the 
inferior  labial,  for  the  supply  of  the  lower  lip;  those  from  either 
side  anastomose.  At  the  corner  of  the  mouth  the  facial  gives  off 
the  inferior  and  superior  coronary.  These  branches  pass  inward, 
lying  a  little  beyond  the  edge  of  either  lip  and  situated  beneath 
the  mucous  membrane:  between  it  and  the  muscular  structure  of 
the  lip.    Those  from  either  side  anastomose  freely  with  their  fellows. 

The  facial  vein,  which  accompanies  the  artery,  is  not  tortuous, 
and  lies  superficial  to  the  artery. 

The  facial  nerve  supplies  the  muscles  of  expression,  etc.,  and 
the  buccinator.  It  emerges  from  the  parotid  gland  upon  the  side 
of  the  face  at  a  point  corresponding  to  the  lower  border  of  the  lobe 
of  the  ear,  and  divides  into  branches  which  supply  the  facial  mus- 
cles and  the  platysma.  The  sensory  supply  to  the  face  and  teeth 
is  derived  from  the  fifth  nerve. 

The  Skeleton  oe  the  Face. — The  upper  part  consists  of  the 
superior  maxillary  and  the  adjoining  bones  with  which  it  articulates 
and  which  serve  to  join  it  to  the  skull;  it  articulates,,  toward  the 
middle  line,  with  the  nasal  bones  which  form  the  bridge  of  the  nose 
and  laterally  with  the  malar.  The  malar  bone  forms  the  prominent 
part  of  the  cheek  and  gives  off  a  process  which  passes  backward  and 
unites  with  a  similar  process  from  the  temporal  to  form  the  zygo- 
matic arch. 

The  body  of  the  superior  maxillary  is  pyramidal,  its  base  being 
directed  inward  toward  the  nasal  cavity,  forming  part  of  its  outer 
wall  and  presenting  the  opening  into  the  antrum  of  Highmore;  its 
apex  corresponds  to  its  junction  with  the  malar.     The  upper  surface 


SURGICAL  ANATOMY  OF  THE  FACE.  53 

of  the  superior  maxillary  is  thin  and  forms  the  floor  of  the  orbit.  Its 
anterior  or  facial  surface  is  very  thin  in  places  and  easily  perforated;  it 
is  rather  concave,  and  just  below  the  margin  of  the  orbit  presents  the 
opening  of  the  infra-orbital  canal.  A  canal  descends,  as  an  offshoot 
from  the  infra-orbital  canal,  through  the  anterior  wall  of  the  bone;  it 
transmits  a  nerve-branch  which  supplies  the  upper  front  teeth.  The 
posterior,  or  zygomatic,  surface  of  the  superior  maxilla  looks  backward 
and  outward  toward  the  zygomatic  fossa;  it  gives  origin,  in  part,  to  the 
external  pterygoid  muscle,  and  is  in  close  relation  with  the  termina- 
tion of  the  internal  maxillary  artery.  This  surface  presents  the 
commencement  of  the  superior  dental  canal  for  the  transmission  of 
the  superior  dental  nerve  to  the  upper  back  teeth. 

The  body  of  the  bone  is  hollowed  out.  The  space  within,  known 
as  the  antrum  of  Highmore,  communicates  with  the  nasal  cavity 
through  an  opening  into  the  middle  meatus,  and  is  lined  with  mu- 
cous membrane,  which  is  continuous  with  that  of  the  nose.  The 
walls  inclosing  the  antrum  are  thin,  but  strengthened  by  columns 
of  bone  which  ascend  from  the  tooth  sockets  and  converge  toward 
the  apex,  malar  process;  in  this  way  the  bone  is  strengthened  and 
the  shock  of  blows  distributed.  The  alveolar  process  is  solid  and 
presents  the  sockets  for  the  teeth.  The  palate  process,  projecting 
inward,  joins  with  its  fellow  of  the  opposite  side,  and  together  with 
the  horizontal  plates  of  the  palate  bones  forms  the  hard  palate:  the 
floor  of  the  nasal,  and  the  roof  of  the  buccal,  cavity. 

The  periosteum  covering  the  upper  jaw  is  thin  and  closely  at- 
tached to  the  surface  of  the  bone.  It  is  rather  more  easily  separated 
from  the  orbital  and  facial  surfaces. 

The  lower  part  of  the  face  is  composed  of  the  inferior  maxillary, 
which  consists  of  a  body  and  two  rami  and  which  is  attached  to  the 
skull  through  the  temporo-maxillary  articulations.  The  body  of  the 
bone  is  horseshoe-shaped,  presenting  an  upper  border,  with  sockets 
for  the  teeth,  and  a  lower  rounded  border,  which  may  be  felt  beneath 
the  integument. 

To  the  inner  surface  of  the  body  of  the  inferior  maxillary  are 
attached  the  muscles  which  form  the  floor  of  the  mouth,  and  in 
front,  at  the  symphysis,  are  attached  the  muscles  which  draw  the 
tongue  forward  and  prevent  its  dropping  back  into  the  pharynx. 

The  ramus  is  a  perpendicular  plate  of  bone  with  an  upper 
curved  border  which  presents,  in  front,  a  thin,  pointed  process,  the 
coracoid,  to  which  is  attached  the  tendon  of  the  temporal  muscle, 


54  HEAD  AND  FACE. 

and,  behind,  a  rather  thickened  process,  the  condyle.  The  upper 
surface  of  the  condyle  is  rounded  and  smooth,  for  articulation  with 
the  glenoid  cavity.  Below  the  articular  surface  there  is  a  rather 
constricted  portion,  known  as  the  neck.  To  the  front  surface  of 
the  neck  of  the  condyle  is  attached  the  tendon  of  the  external 
pterygoid  muscle.  The  lower  posterior  corner  of  the  ramus  is  a 
prominent  landmark,  and  is  called  the  angle  of  the  jaw.  The  outer 
surface  of  the  ramus  is  covered  by  the  masseter  and  gives  attach- 
ment to  this  muscle.  The  inner  surface  of  the  ramus  presents, 
about  its  middle,  the  orifice  of  the  inferior  dental  canal,  into  which 
the  nerve  of  the  same  name  passes  to  supply  the  teeth  of  the  lower 
jaw.  The  anterior  margin  of  this  orifice  is  marked  by  a  small  pointed 
process  of  bone,  to  which  the  long  internal  lateral  ligament  is  at- 
tached. The  internal  pterygoid  muscle  is  attached  to  the  lower 
posterior  part  of  the  inner  surface. 

Sixteen  teeth  are  inserted  in  each  jaw,  eight  on  a  side:  two 
incisors  nearest  the  middle  line,  and,  following  these,  one  canine, 
two  bicuspids,  and  three  molars. 

The  Mouth. — The  mouth  is  inclosed  by  the  lips  and  cheeks. 

The  lips  are  composed  of  fatty  connective  tissue  and  muscular 
tissue,  and  are  covered  externally  by  the  skin  and  internally  by 
the  mucous  membrane.  The  muscular  fibers  are  found  in  the  sub- 
cutaneous connective-tissue  layer,  coming  from  all  directions  and 
interlacing  with  each  other,  and  with  much  fatty  tissue  interspersed 
between  them.  The  mucous  membrane,  lining  the  inner  surface  of 
the  lips,  is  continued  over  upon  the  gums.  In  the  middle  line,  from 
the  lip  to  the  gum,  there  is  a  thin,  delicate  fold  of  mucous  mem- 
brane, the  fraenum,  which  is  well  seen  when  the  lip  is  drawn  away 
from  the  gum.  The  vessels  to  the  lips  are  the  labial  and  the  in- 
ferior coronary  to  the  lower  lip,  and  the  superior  coronary  to  the 
upper  lip.     These  branches  are  derived  from  the  facial. 

The  cheeks  are  formed  of  skin,  connective  tissue  and  fat,  buc- 
cinator muscle,  and  mucous  membrane.  The  buccinator  muscle  is 
attached  to  the  outer  surface  of  the  upper  and  lower  jaw-bones  just 
beyond  the  alveolar  processes.  This  muscle  is  covered,  upon  its 
external  surface,  by  a  layer  of  fascia,  bucco-pharyngeal,  which  is  con- 
tinuous behind  with  that  covering  the  constrictors  of  the  pharynx. 
The  mucous  membrane  lining  the  inner  surface  of  the  cheeks  is 
continuous  with  that  of  the  gums.  The  buccal  cavity  may  be  divided 
into  an  outer  space,  the  vestibule,  and  an  inner  space,  the  mouth 


SURGICAL  ANATOMY  OF  THE  FACE.  55 

proper.  The  vestibule  is  the  space  between  the  teeth  and  the  cheeks 
and  lips.  When  the  mouth  is  closed  the  mucous  membrane  lining 
the  cheeks  is  thrown  into  folds,  which  would  be  caught  between  the 
teeth  if  not  prevented  by  the  contraction  of  the  buccinator  to  which 
the  mucous  membrane  is  firmly  attached. 

Opposite  the  second  upper  molar  tooth  is  the  orifice  of  Stenson's 
duct.  At  times  this  orifice  is  marked  by  a  papilla,  which  may  assist 
one  in  locating  it. 

The  mucous  membrane,  from  the  lips  and  cheeks,  is  reflected 
upon  the  alveolar  process  of  the  upper  and  lower  jaw  and  extends 
between  the  teeth.  It  is  intimately  united  with  the  periosteum  cov- 
ering the  bone,  and  together  with  it  forms  the  gums.  Behind  the 
last  molar  tooth  the  anterior  border  of  the  ramus  of  the  jaw  may 
be  felt,  and  upon  the  outer  side  of  this  the  masseter  muscle  may 
also,  when  contracted,  be  distinctly  recognized.  When  the  teeth  are 
tightly  closed,  the  vestibule  communicates  with  the  cavity  of  the 
mouth  proper  by  a  small  space  behind  the  last  molar  tooth  upon 
either  side. 

The  cavity  of  the  mouth  proper  presents  a  roof  and  a  floor,  and 
is  bounded  in  front  and  upon  the  sides  by  the  alveolar  processes  and 
the  teeth.  Behind,  the  mouth  opens  into  the  pharynx.  It  is  sepa- 
rated from  the  larynx  by  the  epiglottis,  and  from  the  posterior  nasal 
space  by  the  soft  palate.  Where  the  cavity  of  the  mouth  opens  into 
the  pharynx  it  is  somewhat  narrowed  and  is  called  the  isthmus  of 
the  fauces.  The  isthmus  is  bounded  above  by  the  free  edge  of  the 
soft  palate;  below,  by  the  tongue;  and,  upon  the  sides,  by  the  pillars 
of  the  fauces. 

The  roof  of  the  mouth  is  divided  into  the  hard  and  soft  palate. 
The  hard  palate  is  formed  by  the  junction,  in  the  middle  line,  of 
the  palatal  processes  of  the  superior  maxillaries  in  front,  and  of  the 
horizontal  plates  of  the  palate  bones,  behind.  It  is  concave,  and 
arched  from  side  to  side  and  from  before  backward.  In  front,  in 
the  middle  line,  just  behind  the  incisor  teeth,  is  a  foramen,  the 
orifice  of  the  anterior  palatine  canal,  which  transmits  the  anterior 
palatine  vessels.  Extending  from  this  foramen,  forward  and  out- 
ward, to  a  point  between  the  lateral  incisors  and  the  canine  teeth, 
on  either  side,  may  be  seen,  occasionally,  a  line  which  marks  the 
junction  of  the  intermaxillary  bone  with  the  palatal  processes  of 
the  superior  maxillaries. 

Near  the  posterior  edge  of  the  hard  palate,  just  to  the  inner 


56  HEAD  AND  FACE. 

side  of  the  last  molar  tooth,  is  the  orifice  of  the  posterior  palatine 
canal,  and  passing  forward  from  this  is  a  groove,  close  to  the  alveolar 
process.  The  posterior  palatine  vessels  descend,  through  the  poste- 
rior palatine  canal  and  then  pass  forward,  upon  the  hard  palate, 
lying  in  the  groove  just  mentioned.  Behind  the  orifice  of  the  poste- 
rior palatine  canal  may  be  seen  the  hook-like  hamUlar  process:  the 
termination  of  the  internal  pterygoid  process,  around  which  the 
tendon  of  the  tensor  palati  is  reflected  before  it  spreads  out  in  the 
soft  palate.  The  mucous  membrane  and  periosteum,  which  cover 
the  hard  palate,  are  intimately  united  with  each  other  and  to  the 
surface  of  the  bone.  There  is  little  or  no  anastomosis  between  the 
vessels  across  the  middle  line;  so  that  in  operating  for  cleft  palate 
it  is  desirable  to  retain  the  arteries  in  the  flaps  (Langenbeck). 

The  soft  palate  is  a  curtain-like  structure  suspended  from  the 
posterior  border  of  the  hard  palate.  It  is  composed  of  the  spread- 
out  aponeuroses  of  the  tensor  and  levator  palati.  It  marks  the 
boundary  line  between  the  mouth  and  the  pharynx.  It  presents  an 
inferior,  or  anterior,  and  a  superior,  or  posterior,  surface,  each  cov- 
ered with  mucous  membrane. 

The  lower,  or  free,  border  of  the  soft  palate  presents,  in  the 
middle  line,  the  uvula  and  upon  either  side  separates  into  the  ante- 
rior and  posterior  pillars  of  the  fauces.  The  anterior  pillar  is  con- 
tinued downward  into  the  side  of  the  base  of  the  tongue  at  a  point 
just  behind  the  last  molar  tooth  of  the  lower  jaw,  and  is  made  up 
of  the  palato-glossus  muscle.  The  posterior  pillar  is  continued 
downward  and  backward  into  the  side  of  the  pharynx,  and  is  com- 
posed of  the  palato-pharyngeus  muscle.  Between  the  two  pillars  of 
the  fauces  there  is  a  triangular  space  in  which  the  tonsil  is  lodged. 
Just  above  the  soft  palate,  in  the  side  of  the  pharynx,  is  the  orifice 
of  the  Eustachian  tube;  it  is  about  on  a  level  with  the  floor  of  the 
nose. 

In  quiet  breathing  the  soft  palate  hangs  passive;  but  during 
the  act  of  swallowing  it  becomes  tense,  owing  to  the  contraction  of 
its  muscles,  and  its  free  border  then  comes  into  contact  with  the 
posterior  wall  of  the  pharynx,  thus  shutting  off  the  posterior  nasal 
space  from  the  cavity  of  the  mouth. 

The  floor  of  the  mouth  is  formed  of  soft  parts:  chiefly  by  the 
mylo-hyoid  muscle.  This  muscle  extends  from  the  mylo-hyoid 
ridge,  upon  the  inner  surface  of  the  body  of  the  inferior  maxilla,  to 
the  body  and  greater  cornu  of  the  hyoid  bone,  uniting  with  its  fellow 


SURGICAL  ANATOMY  OF  THE  FACE.  57 

in  the  middle  line.  The  upper  surface  of  the  muscle,  which  is 
directed  toward  the  cavity  of  the  mouth,  is  covered  over  by  the 
mucous  membrane,  beneath  which  are  found,  on  either  side,  the 
sublingual  gland,  Wharton's  duct,  the  gustatory  nerve,  etc.  The 
external  surface  of  the  mylo-hyoid  muscle  forms  part  of  the  floor 
of  the  submaxillary  triangle,  and  is  in  relation  with  the  submaxillary 
gland. 

The  tongue  is  a  muscular  organ  which  projects  upward  and 
forward  from  the  floor  of  the  mouth.  It  is  attached  by  its  base 
and  through  several  muscles  to  the  hyoid  bone,  and  is  connected 
with  the  epiglottis  through  the  glosso-epiglottidean  folds  of  mucous 
membrane.  The  tongue  is  composed  of  a  mass  of  muscular  and 
connective  tissue  interspersed  with  much  fat,  and  is  partly  divided 
into  two  symmetrical  halves  by  a  fibrous  septum.  The  tongue  is 
connected  with  the  hyoid  bone  by  the  hyo-glossus  muscle  on  each 
side;  with  the  styloid  process  by  the  stylo-glossus;  with  the  soft 
palate  by  the  palato-glossus,  and  through  the  genio-hyo-glossus  with 
the  symphysis  of  the  lower  jaw-bone — this  muscle  serves  to  draw 
the  tongue  forward  and  prevents  its  dropping  back  into  the  pharynx 
and  obstructing  breathing. 

When  the  mouth  is  closed  its  cavity  is  almost  completely  occu- 
pied by  the  tongue.  The  anterior  part  of  the  upper  surface  of  the 
tongue  is  in  contact  with  the  hard  palate;  the  posterior  part,  with 
the  soft  palate  and  the  epiglottis.  The  tongue  is  covered  by  mucous 
membrane,  that  covering  the  under  surface  and  sides  of  the  organ 
being  similar  to  that  of  the  rest  of  the  mouth.  That  covering  its 
upper  surface,  dorsum,  is  rough,  marked  by  numerous  glands,  and 
composed  of  a  thick  layer  of  flat  epithelium,  which  gives  it  rather 
a  grayish  color.  If  the  tongue  is  lifted  away  from  the  floor  of  the 
mouth  by  its  tip,  the  attachment  of  its  under  surface  to  the  floor 
of  the  mouth,  in  the  middle  line,  through  a  membranous  band,  the 
frsenum  linguae,  is  seen. 

The  sublingual  glands  consist  each  of  a  number  of  lobules,  and 
are  located  in  the  front  part  of  the  mouth,  upon  either  side  of  the 
frsenum,  resting  upon  the  mylo-hyoid  muscle  and  covered  over  by 
the  mucous  membrane.  The  location  of  the  glands  is  indicated  by 
a  slight  swelling  in  the  floor  of  the  mouth,  which  presents  the  little 
pin-point  orifices  of  their  excretory  ducts. 

Upon  either  side  of  the  frsenum  there  is  a  little  papilla  showing 
the  orifice  of  WTharton's  duct.     This  is  the  excretory  duct  of  the 


58  HEAD  AND  FACE. 

submaxillary  gland;  it  passes  forward,  through  the  floor  of  the 
mouth,  lying  below  and  to  the  -inner  side  of  the  sublingual  gland. 

Each  half  of  the  tongue  is  supplied  by  the  corresponding  lingual 
artery;  this  is  a  large  branch  which  is  given  off  from  the  external 
carotid  just  above  the  greater  cornu  of  the  hyoid  bone.  It  passes  for- 
ward beneath  the  hyo-glossus  muscle,  and  ascends  beneath  this  mus- 
cle to  the  under  surface  of  the  tongue,  where  it  is  continued  forward 
to  its  tip.  The  chief  vein  of  the  tongue  is  the  ranine,  a  large  branch, 
which  passes  backward  upon  the  outer  surface  of  the  hyo-glossus 
muscle  and  terminates  in  the  internal  jugular. 

The  nerves  to  the  tongue  are  the  hypoglossal,  the  gustatory, 
and  the  glosso-pharyngeal.  The  hypoglossal  descends  in  the  neck 
as  far  as  the  point  where  the  occipital  artery  is  given  off  from  the 
external  carotid;  here  it  passes  forward,  above  and  parallel  with 
the  greater  cornu  of  the  hyoid  bone,  resting  upon  the  hyo-glossus 
muscle.  The  gustatory  is  one  of  the  branches  derived  from  the  third 
division  of  the  fifth  nerve.  From  its  origin  it  descends  in  front  of 
the  inferior  maxillary  nerve,  lying  between  the  internal  pterygoid 
muscle  and  the  ramus  of  the  jaw;  here  it  communicates  with  the 
chorda  tympani,  from  the  facial,  and  passing  forward,  beneath  the 
body  of  the  jaw  and  above  the  submaxillary  gland,  gives  off  its 
branches  to  the  submaxillary  ganglion;  continued  forward,  upon  the 
hyo-glossus  muscle,  it  crosses  Wharton's  duct,  and  is  continued 
alongside  the  tongue  to  its  apex,  lying  directly  beneath  the  mucous 
membrane.  The  glosso-pharyngeal  is  of  but  little  surgical  impor- 
tance. It  descends  in  the  neck,  in  front  of  the  internal  jugular  vein 
and  the  internal  carotid  artery,  curving  forward  upon  the  outer  side 
of  the  stylo-pharyngeus  muscle,  to  be  distributed  to  the  base  of  the 
tongue,  etc. 

The  Side  of  the  Face. — Passing  transversely  from  behind  for- 
ward beneath  the  integument,  the  zygomatic  arch  may  be  felt.  This 
bony  arch  is  formed  by  the  junction  of  the  zygomatic  process  of  the 
temporal  with  that  of  the  malar.  It  is  a  prominent  landmark,  and 
serves  to  separate  the  side  of  the  head,  the  temporal  region,  from 
the  side  of  the  face,  the  pterygo-maxillary  region. 

The  Pterygo-maxillary  Eegion  corresponds  to  that  part  of 
the  side  of  the  face  which  is  situated  below  the  level  of  the  zygoma. 

The  skin  of  this  region  is  intimately  connected  with  the  under- 
lying subcutaneous  connective  tissue,  which  is  thick  and  only  loosely 
attached  to  the  fascia  covering  the  masseter  muscle. 


SIDE  OF  THE  FACE.  59 

The  masseter  muscle  is  a  strong,  thick  muscle  arising  by  two 
portions  from  the  lower  border  and  inner  surface  of  the  zygoma.  Its 
fibers  pass  downward,  covering  the  ramus  of  the  jaw,  to  the  outer 
surface  of  which  and  to  the  angle  of  the  jaw  it  is  attached.  It  is 
•covered  by  an  expansion  of  the  cervical  fascia,  which  is  attached 
above  to  the  lower  border  of  the  zygoma.  The  facial  artery  crosses 
the  lower  border  of  the  inferior  maxilla  just  in  front  of  the  masse- 
ter muscle,  grooving  the  bone  in  this  situation  and  passing  upward 
and  forward  across  the  cheek  to  the  side  of  the  nose.  It  is  accom- 
panied by  the  facial  vein,  which  joins  with  a  branch  from  the  tem- 
poro-maxillary  and  thus  constitutes  a  big  branch,  the  temporo-facial, 
which  terminates  in  the  internal  jugular. 

After  the  skin  and  subcutaneous  fat  have  been  removed  in  this 
region  the  parotid  gland  is  exposed.  This  gland  is  situated  upon  the 
side  of  the  face,  reaching  from  the  zygoma,  above,  to  below  the  angle 
of  the  jaw.  It  lies  in  the  space  bounded  by  the  angle  of  the  jaw  and 
the  posterior  border  of  the  ramus  in  front,  and  the  mastoid  process 
behind,  and  extends  forward  upon  the  side  of  the  face,  lying  upon 
the  back  part  of  the  masseter  muscle.  The  parotid  gland  is  covered 
by  a  strong  layer  of  fascia,  which  forms  a  sort  of  fibrous  envelope 
and  sends  prolongations  into  the  gland  to  support  it.  This  fascia  is 
continued  forward  on  to  the  masseter  and  buccinator  muscles,  and 
downward  upon  the  side  of  the  neck,  where  it  is  continuous  with 
the  cervical  fascia.  It  is  also  attached  to  the  angle  of  the  jaw.  The 
duct  of  Stenson  (duct  of  the  parotid  gland)  is  about  two  inches  long 
and  lies  about  a  finger's  breadth  below  the  zygoma,  passing  forward 
across  the  masseter,  at  the  anterior  border  of  which  it  pierces  the 
cheek  to  enter  the  mouth  opposite  the  second  molar  tooth  of  the 
upper  jaw. 

The  facial  nerve,  after  emerging  from  the  styloid  foramen, 
passes  forward  and  downward  into  the  substance  of  the  parotid 
gland.  It  crosses  the  external  carotid  artery  and  divides  in  the 
substance  of  the  parotid  gland  into  several  branches,  which  form 
the  pes  anserinus  and  which  are  distributed  upon  the  side  of  the 
face  to  supply  the  muscles,  etc. 

The  auriculo-temporal  nerve  emerges  upon  the  face  behind  the 
neck  of  the  condyle  of  the  jaw  after  passing  through  the  upper  part 
of  the  parotid  gland.  It  ascends  across  the  root  of  the  zygoma,  in 
front  of  the  ear,  in  company  with  the  temporal  artery,  to  be  dis- 
tributed upon  the  side  of  the  head  (temporal  region). 


60  HEAD  AND  FACE. 

Beneath  the  parotid  gland  or  within  its  substance  the  external 
carotid  artery  divides  into  its  terminal  branches:  the  internal  maxil- 
lary and  the  temporal.  The  temporal  ascends  through  the  substance 
of  the  gland  and  across  the  root  of  the  zygoma,  just  in  front  of  the 
cartilage  of  the  ear,  the  auriculo-temporal  nerve  lying  posterior  to 
it;  and  about  two  inches  above  the  zygoma  it  divides  into  the  ante- 
rior and  posterior  temporal.  These  branches,  lodged  in  the  subcu- 
taneous connective-tissue  layer  of  the  temporal  region,  divide  and 
supply  this  part  of  the  scalp,  anastomosing  anteriorly  with  branches 
from  the  frontal  and  posteriorly  with  the  occipital,  etc.  The  inter- 
nal maxillary  artery  is  not  exposed  until  after  the  removal  of  the 
ramus  of  the  jaw,  etc.  (see  later).  The  temporal  artery  is  accom- 
panied by  the  temporal  vein.  The  temporal  vein  does  not  lie  within 
the  substance  of  the  parotid  gland,  but  superficial  to  it;  it  receives 
many  tributaries,  and  below  the  angle  of  the  jaw  divides  into  two 
branches;  the  posterior  joins  with  the  posterior  auricular  to  form 
the  external  jugular  vein;  the  anterior  joins  with  the  facial  to  form 
a  large  branch,  the  temporo-facial,  which  passes  obliquely  backward 
across  the  upper  part  of  the  superior  carotid  triangle,  to  enter  the  in- 
ternal jugular.  This  branch  is  often  cut  in  extirpating  glands,  etc., 
in  this  part  of  the  neck,  and  may  give  rise  to  profuse  hemorrhage. 

The  deeper  parts  of  this  region  are  exposed  by  dividing  the 
zygomatic  arch  with  the  chisel  or  chain-saw  at  its  anterior  and  poste- 
rior extremities,  and  then,  after  cutting  the  attachment  of  the  tem- 
poral fascia  from  its  upper  border,  turning  the  detached  segment  of 
the  arch,  with  the  attached  masseter,  downward.  There  is  then 
exposed  the  upper  part  of  the  ramus  of  the  jaw,  with  its  coracoid 
process,  to  which  the  tendon  of  the  temporal  is  attached.  This 
process  is  now  cut  away  from  the  ramus,  and,  together  with  the 
attached  tendon  of  the  temporal,  turned  upward,  and  we  then  have 
exposed  to  view  the  pterygo-maxillary  region  proper.  Occupying 
this  space  is  the  external  pterygoid  muscle.  This  muscle  arises,  by 
its  broad  anterior  end,  from  the  under  surface  of  the  great  wing  of 
the  sphenoid  and  from  the  outer  surface  of  the  external  pterygoid 
plate;  behind,  its  narrow  end  is  attached  to  a  depression  in  the 
anterior  surface  of  the  neck  of  the  condyle  of  the  lower  jaw  and  to 
the  anterior  margin  of  the  interarticular  fibrocartilage  of  the  tem- 
poro-maxillary  joint.  Curving  around  its  lower  border  and  passing 
forward  and  upward  upon  its  outer  surface  may  be  seen  the  internal 
maxillary  artery.     This  vessel  gives  off  branches  to  the  adjoining 


SIDE  OF  THE  FACE. 


61 


muscles  and  disappears,  anteriorly,  by  passing  into  the  spheno- 
maxillary fossa  between  the  two  heads  of  the  external  pterygoid 
muscle.  This'  vessel  may  now  be  cut  away  and  the  muscle  cut  short 
at  its  attachment  to  the  condyle  of  the  jaw  and  also  close  to  its 
origin,  and  in  this  way  the  parts  which  lie  beneath  the  external 


Fig  17. — Pterygo-maxillary  Region.  Ramus  of  the  jaw  and  the  zygomatic 
arch  cut  away.  ID,  inferior  dental  nerve;  III,  internal  maxillary  artery; 
L,  lingual,  or  gustatory,  nerve;  PE,  external  pterygoid  muscle;  PI,  internal 
pterygoid  muscle;  SM,  superior  maxillary  (second  division  of  fifth)  nerve 
crossing  the  spheno-maxillary  fossa  from  behind  forward. 


pterygoid  muscle  are  exposed, — the  zygomatic  and  spheno-maxillary 
fossae,  with  their  important  vascular  and  nervous  structures. 

The  zygomatic  fossa  is  that  space  which  is  limited  above  by 
the  prominent  horizontal  ridge  called  the  pterygoid  ridge  which  is 
found  upon  the  under  surface  of  the  great  wing  of  the  sphenoid 


62 


HEAD  AND  FACE. 


about  opposite  the  zygoma.  The  floor  of  the  zygomatic  fossa  is  com- 
posed of  the  under  surface  of  the  great  wing  of  the  sphenoid  (base 
of  the  skull)  from  the  pterygoid  ridge  to  the  base  of  the  pterygoid 
process,  and  also  of  the  surface  of  the  external  plate  of  the  pterygoid 
process.     It  presents  the  foramen  ovale  and  the  foramen  spinosum. 


Fig.  18.— Pterygo-maxillary  Region.  External  pterygoid  muscle  cut  away, 
exposing  external  pterygoid  plate,  etc.  AT,  auriculotemporal  nerve;  ID, 
inferior  dental  nerve;  IM,  internal  maxillary  artery;  L,  lingual,  or  gustatory, 
nerve;  MM,  middle  meningeal  artery;  PI,  internal  pterygoid  muscle;  BM, 
superior  maxillary  (second  division  of  the  fifth)  nerve  passing  across  the 
spheno-maxillary  fossa. 


The  spheno-maxillary  fossa  is  the  narrow  perpendicular  space 
which  is  bounded  in  front  by  the  posterior  aspect  of  the  superior 
maxilla  and  behind  by  the  front  of  the  pterygoid  process.  Its  inner 
wall  is  formed  by  the  vertical  plate  of  the  palate  bone  and  consti- 
tutes a  part  of  the  lateral  wall  of  the  nasal  cavity.    Above,  this  space 


SIDE  OF  THE  FACE.  63 

is  bounded  by  the  orbital  process  of  the  palate  bone  and  the  body 
of  the  sphenoid.  The  inner  wall  presents,  above,  the  spheno-palatine 
foramen,  through  which  it  communicates  with  the  nasal  cavity  and 
below  the  upper  opening  or  commencement  of  the  posterior  palatine 
canal.  Into  the  upper  part  of  this  fossa,  upon  its  posterior  wall, 
the  foramen  rotundum  opens;  above  and  internal  to  this  is  the 
opening  of  the  Vidian  canal.  The  anterior  wall  of  this  space  pre- 
sents the  commencement  of  the  infra-orbital  canal. 

Located  between  the  inner  surface  of  the  condyle  of  the  lower 
jaw  and  the  internal  lateral  ligament  is  the  first  part  of  the  internal 
maxillary  artery;  in  this  situation  the  vessel  gives  off  the  middle 
meningeal  branch,  which  passes  directly  upward  and  enters  the  skull 
through  the  foramen  spinosum.  The  middle  meningeal  artery,  at 
its  origin,  is  surrounded  by  the  two  roots  of  the  auriculo-temporal 
nerve;  these  two  roots  join  posteriorly  to  form  the  auriculo-tem- 
poral, which  passes  backward,  as  far  as  the  temporal  artery,  and, 
after  emerging  from  the  upper  part  of  the  parotid  gland,  ascends  in 
front  of  the  ear,  to  be  distributed  to  the  integument  of  the  temporal 
region. 

A  little  in  front  and  to  the  inner  side  of  the  middle  meningeal 
artery  may  be  observed  the  inferior  maxillary  division  of  the  fifth 
nerve.  This  trunk  consists  of  a  large  sensory  root  and  a  smaller 
motor  root,  which  emerge  from  the  skull  through  the  foramen  ovale 
and  join  together  outside  this  opening,  just  below  the  base  of  the 
skull,  to  form  the  inferior  maxillary  division. 

The  inferior  maxillary  division  gives  off  two  temporal  branches, 
which  pass  upward  beneath  the  temporal  muscle,  and  two  large 
branches,  which  pass  downward  and  forward.  One  of  these,  the 
lingual  or  gustatory,  is  joined  below  by  the  chorda  tympani,  a  branch 
of  the  facial,  and  the  other,  the  inferior  dental,  enters  the  canal  on 
the  inner  surface  of  the  ramus  of  the  jaw  to  supply  the  lower  teeth. 
Attached  to  the  inner  posterior  aspect  of  the  inferior  maxillary 
division  is  the  otic  ganglion;  it  is  located  just  below  the  foramen 
ovale. 

In  the  upper  part  of  the  spheno-maxillary  fossa  is  seen  the 
middle,  or  superior  maxillary,  division  of  the  fifth  nerve.  This 
nerve  leaves  the  skull  through  the  foramen  rotundum,  passes  for- 
ward, across  the  upper  part  of  the  spheno-maxillary  fossa  and,  as 
the  infra-orbital,  and  accompanied  by  the  terminal  branch  of  the 
internal  maxillary  artery,  enters  the  infra-orbital  canal,  and  is  finally 


64  HEAD  AND  FACE. 

distributed  to  the  skin  of  the  front  of  the  face,  below  the  orbit. 
Suspended  from  the  lower  border  of  the  middle  division,  as  it  passes 
across  the  upper  part  of  the  spheno-maxillary  space,  is  Meckel's 
ganglion,  with  its  descending  palatine  branches,  etc. 

We  may  now  remove  rather  more  of  the  ramus  of  the  jaw  in 
order  to  expose  more  completely  the  internal  pterygoid  muscle. 
This  is  seen  to  arise  from  the  inner  surface  of  the  external  pterygoid 
plate,  and,  passing  downward,  backward,  and  outward,  is  attached 
to  the  inner  surface  of  the  angle  of  the  jaw.  Between  this  muscle 
and  the  inner  surface  of  the  ramus  of  the  jaw  are  the  inferior  dental 
nerve,  which  enters  the  canal  on  the  inner  surface  of  the  ramus,  and 
the  lingual,  which  is  joined  by  the  chorda  tympani.  The  internal 
lateral  ligament  of  the  jaw  may  also  be  seen  in  this  dissection. 

OPERATIONS  UPON  THE  FACE. 

Resection  of  the  Upper  Jaw. — The  chief  danger  in  this  operation 
is  from  the  entrance  of  blood  into  the  larynx.  This  may  be  avoided 
by  previously  ligating  the  external  carotid  or  by  a  preliminary 
tracheotomy  and  the  use  of  a  Trendelenburg  tampon  cannula;  or  an 
ordinary  tracheotomy  tube  may  be  used,  in  this  latter  case  packing 
the  pharynx,  through  the  mouth,  with  a  gauze  pad.  The  operation 
may  be  done  without  a  preliminary  tracheotomy  by  operating  with 
the  patient  in  the  Eose  position,  the  head  hanging  over  the  end  of 
the  table,  so  that  the  field  of  operation  is  upon  a  lower  level  than 
the  larynx.  It  is  said  that  the  dependent  position  of  the  head,  the 
Eose  position,  favors  venous  hemorrhage,  which  would  be  a  dis- 
advantage. The  operation  may  be  done  with  the  patient  in  a  half- 
sitting  position,  using  incomplete  morphin-chloroform  narcosis,  the 
patient  being  but  partly  ansesthetized,  and  therefore  able  to  cough 
and  keep  the  larynx  clear  of  blood. 

The  incision  should  be  so  placed  as  to  avoid  Stenson's  duct. 

Webee's  Incision. — Eeaching  from  the  inner  angle  of  the  eye, 
the  incision  is  carried  down  alongside  of  the  nose  and  around  the 
ala  to  the  middle  line,  terminating  by  splitting  the  upper  lip.  To 
this  is  added  a  second  incision  reaching  from  the  inner  angle  of  the 
eye,  outward,  below  the  lower  margin  of  the  orbit.  This  second 
incision  should  pass  along  the  lower  edge  of  the  orbicularis  pal- 
pebrarum in  order  to  avoid  cutting  into  the  substance  of  this  muscle. 
These  incisions  should  penetrate  to  the  bone.    Branches  of  the  facial 


OPERATIONS  UPON  THE  FACE. 


65 


nerve  are  not  cut  in  this  incision.  The  flap  which  is  thus  marked  out 
is  reflected  outward,  and  should  be  raised  subperiosteal^  if  the  char- 
acter of  the  disease  permits.  The  infra-orbital  vessels  and  nerve  are 
cut  when  the  flap  is  separated  from  the  anterior  surface  of  the  supe- 
rior maxilla. 


Fig.  19.— Resection  of  Upper  Jaw.    L,  Langenbeck  incision;  V,  Velpeau 
incision;  W,  Weber  incision. 


Langenbeck's  Incision. — A  flap,  its  lower  border  curved  with 
the  convexity  downward,  is  raised.  The  incision  commences  at  the 
inner  angle  of  the  eye,  and  passes  down  alongside  of  the  nose  to  a 
point  below  the  level  of  the  ala,  as  far  as  the  attachment  of  the 
upper  lip  to  the  alveolar  process  of  the  superior  maxilla;  here  it 
curves  outward,  corresponding  to  a  line  drawn  from  the  ala  of  the 


66  HEAD  A:NrD  FACE. 

nose  to  the  lower  border  of  the  lobe  of  the  ear,  and  is  then  carried 
upward  to  a  point  over  the  prominence  of  the  cheek-bone.  This 
incision  does  not  divide  the  lip,  but  it  will  be  necessary  later  to 
separate  the  lip  from  its  attachment  to  the  jaw-bone.  It  divides  some 
branches  of  the  facial  nerve,  which  is  a  disadvantage.  The  front 
surface  of  the  bone  is  exposed  by  reflecting  this  flap  upward,  sub- 
periosteally,  if  the  conditions  permit.  In  raising  the  flap  from  the 
bone  the  infra-orbital  vessels  and  nerve  are  divided. 

In  making  either  of  these  incisions  the  facial  artery  is  divided 
and  must  be  clamped  and  ligated. 

After  the  soft  parts  have  been  detached  from  the  bone  the 
cartilage  of  the  nose  is  separated  from  the  nasal  notch,  and  the 
soft  parts,  corresponding  to  the  lower  margin  of  the  orbit,  raised 
from  the  bone,  and  the  tarso-orbital  fascia  cut  along  the  margin 
of  the  orbit.  The  floor  of  the  orbit  is  now  exposed,  and  the  con- 
tents of  the  orbit  raised  out  of  the  way  with  a  blunt  retractor.  We 
are  then  ready  to  cut  through  the  nasal  process  of  the  superior 
maxillary.  This  division  should  extend  from  the  margin  of  the 
nasal  notch,  across  the  nasal  process,  as  far  as  the  lacrymal  groove 
or  fossa.  One  should  avoid  injury  to  the  lacrymal  sac,  the  upper 
expanded  part  of  the  lacrymal  canal,  which  is  lodged  in  the  lacrymal 
depression  upon  the  lacrymal  bone.  The  'division  of  this  process  of 
bone  may  be  accomplished  with  a  chisel,  or  one  may  make  a  hole 
in  the  lacrymal  bone,  which  is  very  thin,  just  in  front  of  the  lacrymal 
sac,  and  introduce  through  the  orbit  a  Gigli  saw,  bringing  its  end 
out  through  the  nasal  notch;  the  Gigli  saw  is  carried  around  the 
bone  with  a  loop  of  silk  in  a  curved  needle.  Probably  a  chisel  is 
more  convenient  for  this  part  of  the  operation. 

We  next  separate  the  jaw  from  its  attachment  to  the  malar 
bone.  This  may  be  done  with  a  chisel  or  with  a  chain  or  G-igli  saw. 
The  line  of  division  should  extend  through  the  maxillary  process 
of  the  malar  bone  into  the  anterior  end  of  the  spheno-maxillary 
fissure.  If  this  section  is  made  with  a  chain  or  Gigli  saw,  the  instru- 
ment may  be  carried  around  the  bone  with  a  loop  of  strong  silk  in 
a  large,  full-curved  needle.  The  contents  of  the  orbit  being  well 
retracted,  the  needle  is  passed  into  the  orbit,  through  the  spheno- 
maxillary fissure,  and  then  out  through  the  zygomatic  fossa,  emerg- 
ing upon  the  face  below  the  malar  process;  the  suture  is  then  pulled 
through,  drawing  the  saw,  which  thus  surrounds  the  malar  bone  at 
its  junction  with  the  superior  maxillary,  after  it;    the  division  may 


OPERATIONS  UPON  THE  FACE.  67 

then  be  readily  made.  If  it  is  desired  to  take  the  malar  bone  away 
in  addition  to  the  superior  maxillary,  the  needle,  after  entering  the 
spheno-maxillary  fissure,  as  above  described,  should  be  made  to 
traverse  the  temporal  fossa,  appearing  above  the  upper  border  of 
the  malar  bone,  thus  surrounding  its  frontal  process;  after  this 
process  has  been  divided  the  zygomatic  arch  may  be  cut  through 


Fig.  20.— Resection  of  Upper  Jaw.  When  it  is  desired  to  leave  the  major 
part  of  the  malar  bone,  the  line  cf  section  through  the  bone  should  be  as 
indicated  upon  the  right  side  of  the  skull.  If  the  malar  bone  is  to  be  re- 
moved together  with  the  superior  maxillary,  the  section  through  the  bone 
should  be  as  is  represented  upon  the  left  side  of  the  skull,  the  line  of  division 
passing  through  the  frontal  process  of  the  malar  and  the  zygoma. 


with  the  chisel,  thus  separating  the  malar  bone  from  its  connection 
with  the  temporal  bone. 

We  are  then  ready  to  make  the  division  through  the  hard  palate; 
this  is  best  done  as  the  last  step  of  the  operation,  after  the  other 
connections  have  been  severed,  on  account  of  the  hemorrhage  into 
the  mouth.  Before  dividing  the  hard  palate  the  muco-periosteal 
layer,  which  covers  it,  is  detached.  An  incision  is  made  in  the  muco- 
periosteal  covering  of  the  hard  palate,  commencing  anteriorly  just 


68  HEAD  AND  FACE. 

behind  the  incisor  teeth;  this  is  carried  back  along  the  side  of  the 
hard  palate,  close  to  the  alveolar  process,  as  far  as  the  attachment  of 
the  soft  palate  to  the  posterior  border  of  the  hard  palate.  "With  a 
periosteum  elevator,  this  layer  is  separated  from  the  surface  of  the 
hard  palate,  as  far  as  the  middle  line;  the  soft  palate  is  also  separated 
from  the  corresponding  half  of  the  posterior  border  of  the  hard  pal- 
ate. A  chisel  is  then  placed  in  the  middle  line  between  the  two  in- 
cisor teeth,  and  the  hard  palate  divided  down  the  middle  for  its 
whole  length.  It  is  probably  better,  in  some  cases,  to  accomplish 
this  division  with  a  saw.  For  this  purpose  we  use  a  narrow  saw, 
which  is  introduced  into  the  nasal  cavity,  after  the  first  incisor  tooth 
of  the  jaw  which  is  to  be  excised  has  been  extracted,  sawing  through 
the  floor  of  the  nasal  cavity  from  above  downward  and  from  before 
backward. 

The  jaw-bone  is  now  free  except  for  its  attachment,  behind,  to 
the  palate  bone  and  to  the  pterygoid  plate  of  the  sphenoid.  The 
floor  of  the  orbit,  which  is  very  thin,  may  be  cut  through,  just  behind 
its  anterior  margin,  with  one  or  two  strokes  of  the  chisel,  this  line 
of  section  reaching  from  the  lacrymal  fossa  across  the  floor  of  the 
orbit  into  the  spheno-maxillary  fissure.  One  should  finally  see  that 
the  soft  parts  are  separated  from  the  facial  surface  of  the  bone,  well 
beyond  the  last  molar  tooth;  this  may  be  done  with  a  few  sweeps 
of  the  knife,  cutting  close  to  the  surface  of  the  bone. 

The  body  of  the  jaw  is  now  seized  with  a  strong  bone  forceps, 
and,  with  a  gradually  increasing  rocking  motion,  it  is  forcibly 
wrenched  from  its  remaining  attachment.  Usually  all  of  the  palate 
bone,  except  its  orbital  process,  comes  away  with  the  superior 
maxilla  and  there  is  left  remaining  a  part  of  the  orbital  surface  of 
the  superior  maxilla  sufficient  to  support  the  contents  of  the  orbit. 
If  part  of  the  pterygoid  process  comes  away  with  the  superior  max- 
illary, the  bone  will  still  be  held  by  some  of  the  muscles  which  arise 
from  this  process, — the  internal  and  external  pterygoids, — and  it 
will  be  necessary  to  divide  these  with  a  sweep  of  the  knife  before 
the  bone  can  be  removed. 

There  is  left  a  large  bloody  space,  but,  as  a  rule,  there  is  little 
or  no  hemorrhage,  owing  to  the  tearing  of  the  blood-vessels  in 
wrenching  the  bone  free.  The  infra-orbital  vessels  and  nerve  may 
be  seen  hanging  free  in  the  wound.  The  vessels,  which  may  bleed 
freely,  should  be  seized  at  once,  clamped,  and  tied,  and  the  nerve 
cut  short.    The  other  branches  of  the  internal  maxillary  artery  also 


OPERATIONS  UPON  THE  FACE.  69 

are  exposed, — the  descending  palatine  and  spheno-palatine, — and 
these  should  also  be  clamped  and  tied. 

The  wound  may  now  be  irrigated  and  tamponed,  the  ends  of 
the  gauze  emerging  through  the  nostril.  The  incision  upon  the 
face  is  closed  with  interrupted  silk  sutures,  but,  before  doing  this, 
the  edge  of  the  muco-periosteal  flap,  which  was  raised  from  the 
surface  of  the  hard  palate,  should  be  sutured,  with  interrupted  silk 
sutures,  to  the  inner  side  of  the  cheek,  along  the  line  where  this  was 
separated  from  the  alveolar  process  of  the  superior  maxilla.  The 
ends  of  these  sutures  should  be  left  rather  long  and  presenting  into 
the  mouth,  to  facilitate  their  removal  later. 

During  the  operation  the  back  of  the  mouth  and  the  pharynx 
may  be  kept  clear  of  blood  with  gauze  pads  on  long  holders. 

Total  Resection  of  Both  Superior  Maxillae. — This  operation  is 
analogous  to  the  preceding. 

A  curved  incision,  passing  from  the  angle  of  the  mouth  outward 
and  upward  to  the  malar  bone  on  each  side,  or  a  double  Weber  in- 
cision, may  be  used. 

The  nasal  septum,  vomer,  is  divided  with  bone  scissors,  and  the 
soft  parts,  as  a  whole,  including  the  nose,  are  then  detached  and 
reflected  upward,  or,  if  a  double  Weber  incision  is  used,  the  lateral 
flaps  are  separated  from  the  bone  and  reflected  outward. 

The  attachments  of  the  superior  maxillae  are  then  divided  as  in 
the  preceding  operation,  except  that  it  will  not  be  necessary  to  split 
or  cut  through  the  hard  palate,  as  this  is  taken  away  entirely.  If 
possible,  the  muco-periosteal  covering  of  the  hard  palate  should  be 
stripped  off  and  preserved;  this  is  done  by  separating  it,  with  an 
elevator,  through  a  curved  incision  which  penetrates  through  this 
layer  down  to  the  bone  and  which  is  placed  just  inside  the  line  of 
the  teeth.  The  soft  palate,  at  its  attachment  to  the  posterior  border 
of  the  hard  palate,  is  also  completely  separated.  Finally,  with  lion- 
jaw  forceps,  the  bone  is  forcibly  wrenched  free,  as  in  the  preceding 
operation. 

The  soft  parts  are  then  brought  together  with  silk  sutures,  first 
uniting  the  edge  of  the  muco-periosteal  flap,  which  was  raised  from 
the  hard  palate,  to  the  inner  side  of  the  cheeks,  corresponding  to 
the  line  where  they  were  separated  from  the  alveolar  process. 

To  Drain  the  Antrum  of  Highmore.  Thbough  the  Tooth 
Socket. — Empyema  is  frequently  associated  with  carious  teeth. 
These  or  their  remaining  roots  may  be  extracted  and  an  opening 


70  HEAD  AND  FACE. 

made  into  the  antrum  by  gouging  out  the  alveolar  cavity,  which  is 
often  found  to  be  carious.  This  may  be  done,  as  a  rule,  with  a  sharp 
spoon  or  with  a  narrow  chisel.  The  chisel  should  be  directed  upward 
toward  a  point  corresponding  to  the  middle  of  the  lower  margin 
of  the  orbit.  Such  an  opening,  if  made  sufficiently  large,  provides 
satisfactory  drainage  from  the  antrum.  A  strip  of  gauze  may  be 
introduced  to  drain  the  cavity  and  to  prevent  the  entrance  of  par- 
ticles of  food.  The  opening  should  be  made  through  the  alveolus 
of  the  second  biscuspid,  or,  better,  the  first  molar  tooth. 

Through  the  Anterior  Wall. — Drainage  may  be  established 
by  making  an  opening  through  the  front  wall  of  the  antrum.  The 
upper  lip  is  everted  and  the  mucous  membrane  cut  and  the  soft  parts 
separated  from  the  front  surface  of  the  bone  with  the  periosteum 
elevator.  The  front  wall  of  the  antrum  is  perforated  through  the 
canine  fossa  just  above  and  to  the  outer  side  of  the  canine  tooth. 
The  socket  of  this  tooth  is  marked  by  a  prominent  ridge. 

After  the  periosteum  has  been  stripped  off  the  bone  a  good- 
sized  opening  is  made  into  the  antrum  with  the  chisel  or  with  a 
strong,  sharp-pointed  perforator  or  with  a  drill.  The  instrument 
should  be  directed  upward  and  somewhat  backward  toward  the  floor 
of  the  orbit,  but  care  should  be  taken  to  avoid  entering  the  antrum 
abruptly  with  such  force  as  to  endanger  the  floor  of  the  orbit.  A 
drainage  tube  may  be  introduced  and  left  in  place  for  several  days 
until  the  drainage  opening  is  well  established.  It  is  advisable  to 
use  a  tube  with  a  bulbed  end  to  prevent  its  slipping  out. 

This  operation  may  well  be  combined  with  drainage  through  the 
tooth  socket  as  described  above.  Both  operations  may  be  done  with 
the  patient  in  the  Eose  position  or  with  partial  morphin-chloroform 
anaesthesia. 

Through  the  Lateral  Wall  of  the  Nose. — Mikulicz  advises 
making  an  opening  in  the  lateral  wall  of  the  nose  just  below  the 
middle  of  the  inferior  turbinated.  This  may  be  done  with  a  sharp- 
pointed  perforator  somewhat  bent  upon  itself  near  the  end.  The 
bone  is  thin,  and  the  operation  is  readily  done  except  when  the  nasal 
cavity  is  narrow  or  the  inferior  turbinated  much  hypertrophied. 

Resection  of  Half  of  the  Lower  Jaw. — The  incision  commences 
at  the  middle  of  the  chin  and  follows  along  the  lower  border  of  the 
body  of  the  jaw  as  far  as  the  angle,  whence  it  is  continued  upward 
along  the  posterior  border  of  the  ramus  as  high  as  the  lower  border 
of  the  lobe  of  the  ear  (one  may  cut  to  this  point  without  danger  of 


OPERATIONS  UPON  THE  FACE.  71 

injuring  the  facial  nerve;  see  Fig.  79).  This  incision  for  its  whole 
extent  should  reach  to  the  bone.  There  may  be  added  in  front  a 
vertical  incision,  splitting  the  lower  lip  through  the  middle  line,  but 
this  is  usually  unnecessary.  The  facial  vessels  are  severed  in  making 
the  incision  along  the  lower  border  of  the  body  of  the  jaw-bone,  and 
these  should  be  clamped  and  tied. 

If  the  glands,  etc.,  in  the  submaxillar}'  region  are  diseased,  in- 
stead of  the  above-described  incision  one  may  be  made  which  com- 
mences anteriorly,  in  the  middle  line,  at  the  lower  border  of  the 
jaw,  from  which  point  it  passes  backward  and  somewhat  downward 
across  the  submaxillary  triangle,  deviating  from  the  lower  border 
of  the  jaw  as  it  passes  backward,  as  far  as  the  anterior  border  of  the 
sterno-mastoid  muscle,  whence  it  is  turned  upward  toward  the  apex 
of  the  mastoid  process.  This  incision  passes  through  the  integu- 
ment and  the  platysma.  The  flap  which  is  thus  outlined  is  turned 
up  over  the  side  of  the  face,  and  we  are  then  enabled,  as  a  prelimi- 
nary step,  to  clear  out  the  submaxillary  triangle,  and  before  doing 
this  we  can,  if  desired,  easily  expose  and  ligate  the  external  carotid 
artery.  Some  surgeons  precede  the  operation  with  a  preliminary 
tracheotomy,  introducing  a  tampon  cannula;  or  an  ordinary  tube 
may  be  introduced  and  the  pharynx  tamponed.  These  measures 
eliminate  the  danger  of  blood  being  inspired  into  the  trachea. 

Having  cleaned  out  the  submaxillary  triangle,  or,  if  this  has 
not  been  necessary,  through  the  incision  along  the  lower  border  of 
the  body,  the  soft  parts  are  separated  from  the  external  surface  of 
the  body  and  ramus  of  the  jaw,  back  as  far  as  the  angle,  working 
close  to  the  surface  of  the  bone;  the  attachment  of  the  masseter 
is  thus  separated  from  the  ramus.  The  separation  of  the  masseter 
and,  in  fact,  the  soft  parts  from  the  body  of  the  bone  as  well,  is 
accomplished  with  a  periosteum  elevator,  occasionally  snipping  with 
the  knife.  It  is  desirable,  if  the  nature  of  the  condition  present 
permits,  to  make  this  separation  subperiosteally.  In  the  mass  of 
soft  parts  which  is  raised  from  the  outer  surface  of  the  ramus  of  the 
jaw  are  included,  besides  the  masseter  muscle,  the  parotid  gland  and 
Stenson's  duct,  the  facial  nerve,  and  the  temporal  artery.  None  of 
these  structures  are  injured  if  one  works  close  to  the  surface  of  the 
bone.  ISTow,  with  a  clean  cut,  the  cavity  of  the  mouth  is  entered, 
incising  the  mucous  membrane  close  to  the  anterior  border  of  the 
ramus  and  along  the  dental  margin  of  the  body  of  the  jaw  as  far 
as  the  middle  line;   in  this  way  the  outer  surface  of  the  lower  jaw, 


72  HEAD  AND  FACE. 

including  the  teeth,  is  laid  bare.  Anteriorly,  where  the  body  of  the 
jaw  is  to  be  divided,  a  tooth  is  extracted  and  the  floor  of  the  mouth, 
close  to  the  bone,  incised,  so  that  the  chain  or  Gigli  saw  may  be 
carried  around  the  bone.  This  is  done  with  a  loop  of  strong  silk 
in  a  large  curved  needle,  and  then  the  body  of  the  jaw  is  divided. 
This  division  may  also  be  accomplished  with  a  metacarpal  saw.  The 
section  through  the  body  of  the  jaw,  in  front,  should,  if  possible,  be 
made  a  little  external  to  the  middle  line,  toward  the  side  of  the 
disease,  in  order  to  avoid  separating  the  genio-hyoid  and  genio-hyo- 
glossus  muscles  from  their  attachment  to  the  tubercles  on  the  inner 
aspect  of  the  symphysis  mentis.  If  these  muscles  are  separated  from 
their  attachment  to  the  jaw,  there  is  a  great  tendency,  both  during 
and  after  the  operation,  for  the  tongue  to  drop  back  into  the  pharynx, 
closing  down  the  epiglottis  and  thus  greatly  interfere  with  the  pa- 
tient's breathing. 

After  the  bone  has  been  divided  in  the  middle  line  its  free 
end  is  seized  with  a  bone  forceps  and  drawn  outward,  thus  putting 
the  structures  attached  to  its  inner  surface  (floor  of  the  mouth)  on 
the  stretch,  and  they  are  then  divided  close  to  the  dental  margin 
(teeth)  with  a  scalpel.  If  the  condition  of  the  periosteum  permits, 
these  parts  may  be  separated  from  the  inner  surface  of  the  jaw  sub- 
periosteally  with  an  elevator.  The  body  of  the  bone,  still  firmly 
grasped  with  the  bone  forceps  and  being  now  freely  movable,  is 
dragged  forcibly  downward  and  out  of  the  wound  so  that  the  operator 
can  reach  the  coracoid  process  to  which  the  tendon  of  the  temporal 
muscle  is  attached;  this  is  separated  with  a  knife,  cutting  close  to 
the  bone  and  avoiding  the  internal  maxillary  artery  and  the  bone  is 
then  still  further  luxated.  Behind,  attached  to  the  inner  surface 
of  the  ramus  of  the  jaw,  at  the  angle,  is  the  internal  pterygoid  mus- 
cle; this  is  also  cut  away  close  to  the  surface  of  the  bone. 

The  inferior  dental  vessels  and  nerve  enter  the  jaw-bone 
through  the  inferior  dental  canal  on  the  inner  surface  of  the  ramus; 
these  structures  may  be  cut  or  torn,  but  before  being  cut  they  should 
be  grasped  with  an  artery  forceps;  later  the  vessels  are  tied  and  the 
forceps  removed,  liberating  the  nerve.  If  the  inferior  dental  should 
bleed  in  the  sawn  surface  of  the  bone  this  may  be  stopped  by  plug- 
ging the  orifice  of  the  canal  with  a  strand  of  catgut.  The  flap  of 
soft  parts  is  now  drawn  forcibly  upward,  and  the  bone,  still  held 
with  the  bone  forceps,  dragged  downward;  so  that  the  outer  wall 
of  the  capsule  of  the  temporo-maxillary  joint  may  be  reached  with 


OPERATIONS  UPON  THE  FACE.  73 

the  point  of  a  sharp  knife  and  incised;  the  tendon  of  the  external 
pterygoid,  which  is  attached  to  the  front  of  the  neck  of  the  con- 
dyle, is  likewise  divided.  In  cutting  these  structures  the  knife  is 
kept  applied  close  to  the  surface  of  the  bone  in  order  to  avoid  the 
internal  maxillary  and  the  temporal  arteries.  The  bone  may  now 
be  readily  twisted  out  of  its  socket. 

If  it  should  be  necessary  to  separate  the  muscles  of  the  tongue 
from  their  attachment  to  the  symphysis  of  the  jaw,  a  thick  silk 
ligature  should  be  previously  passed  through  its  tip,  to  be  used  as 
a  tractor  to  prevent  its  being  drawn  backward  into  the  pharynx  and 
closing  the  larynx  and  interfering  with  respiration.  It  is  probably 
advisable  to  introduce  such  a  ligature  in  all  cases. 

The  cut  edge  of  the  mucous  membrane,  which  was  separated 
from  the  inner  aspect  of  the  jaw-bone,  is  now  accurately  sutured  to  the 
corresponding  edge  of  the  mucous  membrane,  which  was  separated 
from  the  outer  aspect,  except  for  a  short  space  behind  through  which 
the  cavity  of  the  mouth  is  drained;  these  sutures  should  be  of  silk, 
knotted  on  the  inside  of  the  mouth,  and  the  ends  left  sufficiently 
long  to  allow  of  their  ready  removal  later. 

The  edges  of  the  skin  are  approximated  with  interrupted  sutures 
except  at  the  posterior  part  where  the  drain  emerges. 

For  the  purpose  of  facilitating  drainage,  the  wound  is  loosely 
packed  with  iodoform  gauze,  reaching  into  the  cavity  of  the  mouth. 
This  may  be  removed  after  a  few  days,  when  a  sinus  is  established 
through  which  all  secretions  from  the  mouth  may  find  exit. 

Resection  of  Half  of  the  Body  of  the  Lower  Jaw.  —  A  strong, 
thick  suture  is  passed  through  the  tongue  for  use  as  a  tractor,  if 
this  becomes  necessary.  An  incision  is  made  along  the  lower  bor- 
der of  the  body  of  the  jaw  from  the  middle  line  in  front  to  the 
junction  of  the  body  and  ramus  just  beyond  the  last  molar,  behind; 
this  incision  penetrates  to  the  bone.  In  many  cases  the  facial  artery, 
where  it  curves  over  the  lower  border  of  the  body  of  the  jaw,  just 
in  front  of  the  masseter,  is  divided;  but  frequently  this  may  be 
avoided.  If  the  vessel  is  cut  it  must  be  clamped  and  ligated.  There 
may  be  added  anteriorly  a  vertical  incision  which  splits  the  lower 
lip  in  the  middle  line;  but,  as  a  rule,  this  is  unnecessary,  and  should  be 
avoided. 

With  the  elevator  or  knife,  working  close  to  the  surface  of  the 
bone,  the  soft  parts  are  separated  from  the  outer  surface  of  the  body 
of  the  jaw,  finally  cutting  through  the  mucous  membrane  close  to 


74  HEAD  AND  FACE. 

the  teeth  and  thus  entering  the  mouth  and  exposing  the  outer  sur- 
face of  the  hody  of  the  bone  and  the  teeth. 

The  floor  of  the  mouth  is  now  perforated,  anteriorly,  near  the 
middle  line,  close  to  the  inner  surface  of  the  bone,  and,  after  ex- 
tracting a  tooth,  the  Gigli  or  chain  saw  is  introduced,  being  carried 
around  the  jaw  with  a  loop  of  silk  in  a  strong  curved  needle,  and  the 
bone  is  then  sawn  through;  this  section  should  be  made  to  the  side 
of  the  middle  line  in  order  not  to  disturb  the  attachment  of  the 
muscles  of  the  tongue  to  the  symphysis.  If  the  end  of  the  divided 
bone  bleeds,  this  may  be  controlled  by  plugging  the  orifice  of  the 
canal  which  contains  the  nutrient  artery.  The  end  of  that  half  of 
the  bone  which  is  to  be  excised  is  now  seized  with  the  bone  forceps 
and  drawn  strongly  outward,  thus  putting  the  soft  parts  attached 
to  its  inner  surface  (floor  of  the  mouth)  upon  the  stretch.  These 
parts  are  separated  from  the  inner  surface  of  the  bone  as  far  back 
as  the  junction  of  the  body  with  the  ramus — beyond  the  last  molar 
tooth.  This  may  be  done  bluntly  with  an  elevator,  separating  sub- 
periosteally,  or,  if  this  is  contra-indicated  on  account  of  the  char- 
acter of  the  disease,  these  parts,  including  the  mucous  membrane, 
may  be  simply  cut  away  from  the  bone  with  the  knife.  After  having 
thus  stripped  the  body  of  the  bone  of  its  soft  parts,  both  upon  its 
outer  and  its  inner  or  buccal  surface,  the  saw  is  applied  just  behind 
the  last  molar  tooth  and  the  bone  cut  through.  This  may  be  done 
with  the  chain  or  G-igli  saw  or  with  a  narrow  metacarpal  saw.  "While 
the  bone  is  being  divided  it  should  be  drawn  well  downward  with 
the  bone  forceps. 

Hemorrhage  from  the  cut  surface  of  the  bone  is  controlled  with 
a  plug  of  catgut,  which  is  packed  into  the  orifice  of  the  dental  canal. 

The  mucous  membrane,  which  was  separated  from  the  outer 
surface  of  the  segment  of  bone  which  has  been  resected,  is  sutured 
to  the  cut  edge  of  the  parts  which  were  separated  from  the  inner 
surface  of  the  bone.  This  closes  in  the  cavity  of  the  mouth,  and 
may  be  done  with  interrupted  silk  sutures  tied  within  the  mouth, 
the  ends  being  left  moderately  long,  so  that  they  may  be  readily 
removed. 

The  incision  in  the  skin  is  closed  in  part,  leaving  the  posterior 
end  open  for  drainage.  It  is  probably  wise,  in  most  cases,  to  leave 
a  small  opening  through  the  mucous  membrane  also,  so  that  the 
cavity  of  the  mouth  may  be  drained;  in  this  case  the  gauze,  which 
is  introduced  into  the  posterior  portion  of  the  skin  incision,  is  packed 
into  the  mouth. 


OPERATIONS  UPON  THE  FACE.  75 

Resection  of  the  Entire  Body  of  the  Lower  Jaw. — This  is  anal- 
ogous to  the  preceding  operation,  but  special  care  must  be  exercised 
to  guard  against  the  tongue  dropping  back  into  the  pharynx  after 
the  attachment  of  the  muscles,  which  pull  it  forward,  have  been 
separated  from  the  inner  surface  of  the  symphysis.  This  accident 
may  be  prevented  by  passing  a  ligature  through  the  tip  of  the  tongue 
by  which  traction  may  be  made. 

There  is  also  considerable  danger  of  the  tongue  dropping  back 
and  obstructing  the  breathing  after  the  operation,  and  this  accident 
might  easily  cause  the  death  of  the  patient;  so  that  the  tractor 
should  be  allowed  to  remain  in  the  tongue  and  fixed  outside.  The 
jaw-bone  is  divided  in  the  middle  line,  and  then  each  half  is  resected 
separately  as  described  in  the  preceding  operation. 

Resection  of  Part  of  the  Body  of  the  Lower  Jaw  in  Continuity. 
Fkom  Within  the  Mouth. — Precautions  must  be  taken  to  prevent 
hlood  entering  the  larynx  during  the  operation  (see  "Kesection  of  the 
Upper  Jaw,"  etc.).  A  mouth-gag  is  introduced  and  an  incision  is  made 
through  the  mucous  membrane  on  either  side  of  the  teeth,  and  the 
soft  parts  separated  from  the  inner  and  outer  surfaces  and  from  the 
lower  border  of  the  segment  of  the  jaw-bone  that  is  to  be  excised,  with 
an  elevator.  A  tooth  is  then  extracted  and  the  Gigli  saw  passed  around 
the  bone  with  a  loop  of  silk  in  a  large  curved  needle  and  the  bone 
divided;  this  procedure  is  repeated  at  the  other  end  of  the  segment 
of  bone  which  is  to  be  excised.  The  hemorrhage  from  the  cut  ends 
of  the  bone  is  controlled  by  a  plug  of  catgut  packed  into  the  dental 
canal.  One  may  separate  the  soft  parts  from  the  surface  of  the 
bone  subperiosteally,  as  above  described,  but  in  most  cases  this  is 
mot  permissible  on  account  of  the  character  of  the  disease.  After 
removal  of  the. segment  of  bone  the  edges  of  the  mucous  membrane 
may  be  brought  together,  at  least  in  part,  by  interrupted  silk  sutures. 
A  small  opening  may  be  made  externally  through  the  skin  for 
drainage. 

If  the  anterior  portion  of  the  body  is  resected,  necessitating  the 
•separation  of  the  tongue  muscles  from  the  symphysis,  proper  meas- 
ures must  be  taken  to  guard  against  the  tongue's  dropping  back 
upon  the  epiglottis  and  larynx.  The  operation  done  from  within 
the  mouth  is  ordinarily  rather  disadvantageous,  as  one  is  unable 
"to  properly  drain  the  wound  afterward. 

From  Without. — An  incision  is  made  along  the  lower  border 
of  the  body  of  the  bone  corresponding  to  that  part  of  the  bone 


76  HEAD  AND  FACE. 

which  is  to  be  resected  and  reaching  down  to  the  surface  of  the  bone. 
Usually  it  is  not  necessary  to  split  the  lower  lip.  The  soft  parts  are 
separated  from  the  outer  surface  of  the  body  of  the  bone  with  the 
elevator,  if  permissible,  subperiosteal^,  and  the  mucous  membrane 
then  incised  close  to  the  teeth,  thus  opening  into  the  mouth.  Corre- 
sponding to  the  points  at  which  the  bone  is  to  be  divided  the  teeth 
are  extracted  and  incisions  made  in  the  floor  of  the  mouth  close  to 
the  bone  to  allow  the  passage  of  the  Gigli  saw;  this  is  carried  around 
the  bone  with  a  loop  of  silk  in  a  full  curved  needle  and  the  bone 
then  divided  from  within  outward.  The  segment  of  bone,  which  has 
been  thus  loosened  and  to  the  inner  aspect  of  which  the  soft  parts 
of  the  floor  of  the  mouth  are  still  attached,  is  seized  with  the  bone 
forceps  and  the  soft  parts  (mucous  membrane  and  muscles  of  the 
floor  of  the  mouth)  are  then  separated  with  the  elevator  or  cut  with 
the  knife  close  to  the  surface  of  the  bone  and  near  its  alveolar  margin. 
Hemorrhage  from  the  bone  may  be  controlled  by  plugging  its  nutrient 
canal  with  a  piece  of  catgut. 

The  mucous  membrane,  which  was  separated  from  the  outer 
surface  of  the  resected  segment,  is  united  to  that  which  was  sepa- 
rated from  the  inner  surface  with  several  interrupted  silk  sutures,, 
tied  within  the  mouth,  in  this  way  closing  in  the  cavity  of  the  mouth. 
The  external  wound  is  partly  closed  and  drained. 

If  the  part  resected  corresponds  to  the  anterior  portion  of  the 
body  of  the  jaw-bone,  one  should  secure  the  tongue  by  passing  a 
silk  suture  through  its  tip. 

Resection  of  Part  of  the  Body  of  the  Lower  Jaw  (Not  Through. 
Entire  Thickness,  Not  in  Continuity) . — Practically  as  described  in  the 
preceding  operation,  working  either  from  within  the  mouth  or  without. 
The  operation  consists  in  resecting  the  diseased  part  of  the  bone  and 
leaving  a  portion  of  the  body,  of  greater  or  less  thickness,  as  a  bridge 
to  preserve  the  continuity  of  the  bone  and  prevent  deformity,  and  to 
facilitate  the  application  of  an  apparatus.  The  removal  of  the  bone 
may  be  effected  with  a  chisel  or  with  the  cutting  bone  forceps.  This 
operation  is  but  seldom  practiced. 

Extirpation  of  the  Casserian  Ganglion  (Rose-Andrews). — The 
incision  commences  at  a  point  near  the  external  angular  process, 
curving  backward  above  the  zygoma  to  a  point  just  in  front  of  the 
ear,  whence  it  extends  downward  to  near  the  angle  of  the  jaw.  This 
incision  penetrates  through  the  skin  and  fat  only,  and  pains  should 
be  taken  to  avoid  injuring  the  parotid  gland,  Stenson's  duct,  and 


OPERATIONS  UPON  THE  PACE.  77 

the  facial  nerve.  The  temporal  artery,  as  it  ascends  in  front  of  the 
ear,  may  be  divided,  in  which  case  it  will  he  necessary  to  ligate  it. 
This  flap  is  reflected  downward  sufficiently  to  expose  the  zygomatic 
arch.  The  temporal  fascia  is  incised  along  the  upper  border  of  the 
zygomatic  arch. 

The  next  step  is  the  division  of  the  zygomatic  arch  with  the 
chain  or  Gigli  saw,  both  in  front  and  behind,  and  the  segment 
which  is  thus  resected,  together  with  the  attached  masseter  mus- 
cle, is  then  reflected  downward.  Before  dividing  the  zygomatic  arch 
holes  should  be  drilled  through  the  bone  corresponding  to  the  in- 
tended line  of  section,  so  that  it  may  be  wired  back  in  place  after 
the  operation  has  been  completed.  When  this  flap,  including  the 
detached  segment  of  the  zygomatic  arch  and  the  masseter  muscle, 
is  turned  down,  the  coraeoid  process  of  the  lower  jaw  and  the  tem- 
poral tendon,  which  is  attached  to  it,  are  exposed.  The  coraeoid 
process  is  now  divided,  first  drilling  holes  for  subsequent  wiring, 
and  together  with  the  attached  tendon  of  the  temporal  muscle, 
this  is  turned  upward.  There  is  now  exposed  the  internal  maxil- 
lary artery,  passing  from  below,  forward,  and  upward  across  the 
outer  surface  of  the  external  pterygoid  muscle.  This  vessel  is  tied 
double  and  divided.  With  the  periosteum  elevator  the  external 
pterygoid  muscle  is  separated  from  its  attachment  to  the  under  sur- 
face of  the  great  wing  and  from  the  outer  surface  of  the  external 
pterygoid  plate  of  the  sphenoid.  All  hemorrhage  should  be  con- 
trolled by  ligature  or  pressure  as  the  operation  progresses  step  by 
step.  Now,  with  the  finger  in  the  wound,  one  should  feel  for  and 
recognize  the  sharp  edge  of  the  external  pterygoid  plate,  and  tracing 
this  upward,  as  a  guide,  feel  or  see  the  foramen  ovale  at  its  base 
(see  Tig.  18). 

A  trephine  of  small  diameter  is  applied  to  the  base  of  the  skull 
(under  surface  of  the  great  wing  of  the  sphenoid,  which  has  been 
laid  bare  by  detaching  the  external  pterygoid)  anterior  and  a  little  ex- 
ternal to  the  foramen  ovale,  and  here  a  small  button  of  bone  is  re- 
moved. After  this  button  of  bone  has  been  removed  the  bridge  of 
bone  remaining  between  the  trephine  opening  and  the  foramen  ovale 
is  cut  away  with  a  rongeur  bone  forceps.  The  third  division  of  the 
fifth  nerve  is  now  seized  with  a  hook  and  drawn  out  through  the  open- 
ing in  the  skull  to  serve  as  a  guide  to  the  Casserian  ganglion,  and  then 
the  second  division  of  the  nerve  is  also  seized  with  the  hook  and  pulled 
out  through  the  opening.     These  trunks  are  then  both  divided  and 


78 


HEAD  AND  FACE. 


used  as  guides  to  the  ganglion,  which  lies  in  a  direction  backward  and 
inward  from  the  foramen  ovale,  within  the  skull,  upon  the  apex  of  the 
petrous  portion  of  the  temporal  bone.  The  cut  ends  of  the  nerves,  still 
attached  to  the  ganglion,  are  steadied  in  the  grasp  of  a  long,  narrow 
artery  forceps,  and  with  a  curette,  introduced  through  the  opening  in 
the  skull,  the  ganglion  is  destroyed  and  scooped  out. 


Fig.  21. — Resection  of  the  Casserian  Ganglion,  etc.  KL,  Kronlein-Liicke 
incision;  RA,  Rose- Andrews  incision.  Dotted  lines  represent  the  lines  of 
division  through  the  bones;  drill  holes  for  subsequent  wiring  of  th.3  frag- 
ments. 


The  technique  of  this  operation  is  difficult,  as  it  is  almost  im- 
possible to  reach  the  ganglion.  There  is  liability  to  profuse  hemor-' 
rhage  which  is  difficult  to  control  and  also  to  injury  of  the  Eustachian 
tube;  so  that  the  danger  of  infection  is  great.  Oozing  can  be  stopped 
by  pressure  with  a  gauze  pad.  When  the  operation  is  finished,  the 
parts  are  replaced,  the  coracoid  being  wired  to  the  ramus  of  the  jaw, 


OPERATIONS  UPON  THE  FACE.  79 

the  segment  of  the  zygomatic  arch  fixed  in  place  with  wire  sutures,, 
and  the  wound  in  the  skin  closed. 

Division  of  the  Second  and  Third  Branches  of  the  Trifacial 
Nerve  at  the  Base  of  the  Skull  (Krdnlein's  Modification  of  Lucke's 
Operation). — This  operation  consists  in  exposing  the  second  and 
third  divisions  of  the  fifth  nerve  as  they  emerge  from  the  skull 
and  dividing  them  or  twisting  them  free  from  their  origin. 

An  incision  marking  out  a  rounded  skin-flap,  with  its  convexity 
downward  and  its  base  corresponding  to  the  upper  border  of  the 
zygomatic  arch,  is  made.  It  commences  anteriorly,  one  finger's 
breadth  behind  the  external  angular  process,  and  terminates  behind,, 
just  in  front  of  the  tragus.  This  flap,  consisting  of  the  skin  and 
subcutaneous  fascia,  is  raised  from  the  deep  fascia  covering  the 
parotid  gland  and  masseter  muscle,  and  is  reflected  upward,  thus- 
exposing  the  arch  of  the  zygoma  and  the  lower  portion  of  the  tem- 
poral fascia,  which  is  attached  to  the  upper  border  of  the  arch. 
The  incision  does  not  reach  low  enough  to  injure  the  facial  nerve 
or  Stenson's  duct.  Bleeding  points  should  be  clamped  and  ligated 
as  the  operation  progresses. 

The  temporal  fascia,  attached  to  the  upper  border  of  the 
zygomatic  arch,  is  now  incised  along  this  border  of  the  arch,  and 
the  arch  sawn  through:  first,  posteriorly  and  then  anteriorly.  Be- 
fore making  this  division  of  the  arch  holes  should  be  drilled  for  the 
purpose  of  wiring  the  detached  segment  in  position  later.  In  dividing 
the  arch  anteriorly  one  should  take  care  to  get  well  forward  so  as  to  in- 
clude as  much  of  the  length  of  the  arch  as  possible;  the  line  of  division 
should  not  be  from  above  directly  downward,  but  from  above 
obliquely  downward  and  forward.  This  segment  of  the  arch,  carry- 
ing the  attached  masseter  muscle  with  it,  is  reflected  downward,, 
exposing  the  coracoid  process  of  the  ramus  of  the  lower  jaw  and 
the  attached  temporal  tendon.  This  process,  after  making  drill  holes 
for  subsequent  wiring,  is  then  cut  away,  the  line  of  section  extending 
from  the  deepest  part  of  the  sigmoid  notch  obliquely  downward  and 
forward  so  as  to  include  practically  all  that  part  of  the  ramus  which 
corresponds  to  the  attachment  of  the  temporal  tendon.  This  seg- 
ment of  bone,  carrying  the  temporal  tendon,  is  reflected  upward, 
and  held  thus  with  a  retractor.  The  external  pterygoid  muscle,  and 
the  internal  maxillary  artery,  which  passes  obliquely  across  its  outer 
surface,  are  now  exposed.  It  is  well  to  tie  the  vessel  double  and 
cut   it.     With  the   elevator  the   attachment   of  the   external  ptery- 


80  HEAD  AND  FACE. 

goid  is  now  separated  from  the  under  surface  of  the  great  wing  of 
the  sphenoid  and  drawn  downward.  The  finger  is  then  introduced 
into  the  space  ahove  the  upper  horder  of  the  muscle  and  is  passed 
inward  close  to  the  under  surface  of  the  bone  (base  of  the  skull), 
feeling  for  the  posterior  sharp  edge  of  the  external  pterygoid  plate 
and  searching  for  the  foramen  ovale,  which  is  directly  behind  and 
a  little  external  to  the  root  or  base  of  the  pterygoid  process,  external 
pterygoid  plate.  We  should  recognize  the  thick  trunk  of  the  in- 
ferior maxillary,  or  third,  division  of  the  fifth  nerve  as  it  emerges 
from  the  foramen  ovale;  directly  behind  this,  the  middle  menin- 
geal arter}^,  surrounded  by  the  two  roots  of  the  auriculo-temporal 
nerve,  is  seen  passing  upward  to  enter  the  skull  through  the  foramen 
spinosum  (see  Fig.  18).  The  inferior  maxillary  division  is  seized  with 
a  hook  and  drawn  forward  and  cut,  and  then  the  stump,  grasped  with 
a  forceps,  is  twisted  free  from  its  origin  at  the  Casserian  ganglion. 
Usually  the  motor  root  is  grasped  at  the  same  time  and  included 
with  it.  We  then  penetrate  into  the  spheno-maxillary  fossa,  and 
in  the  upper  part  of  this  cavity,  the  superior  maxillary,  or  second, 
division  of  the  fifth  nerve,  just  before  it  enters  the  infra-orbital 
canal,  is  seized  with  the  hook  and  drawn  out  and  cut,  and  then  like- 
wise twisted  away  from  the  Casserian  ganglion.  The  Eustachian 
tube  is  located  close  to  the  inner  side  of  the  inferior  maxillary,  or 
third,  division,  and,  therefore,  just  as  soon  as  this  trunk  of  the  nerve 
is  accessible,  one  should  not  penetrate  deeper  into  the  wound  for  fear 
of  cutting  into  the  Eustachian  tube,  which  would  result  in  certain 
infection  of  the  wound. 

The  coracoid  process  is  reunited  to  the  ramus  of  the  jaw  with 
a  wire  suture  and  the  segment  of  the  zygomatic  arch  is  likewise 
replaced  and  wired.     The  skin  incision  is  then  closed. 

CONGENITAL  DEFORMITIES  OF  THE  FACE. 

The  Development  of  the  Face.  —  About  the  twelfth  day  the 
arrangement  of  the  head  end  of  the  embryo  is  quite  simple.  A 
cross  section  shows  it  to  consist  of  two  tubes,  one  being  situated 
in  front  of  the  other.  The  anterior  is  the  blind,  head  end  of  the 
alimentary  tube:  the  future  pharynx.  The  posterior  is  the  enlarged 
neural  tube  which  is  later  developed  into  the  brain.  The  anterior 
wall  of  this  upper,  head  end  of  the  alimentary  tube  is  called  the 
"oral  plate,"  and  marks  the  location  of  the  future  mouth  and  face. 


CONGENITAL  DEFORMITIES  OF  THE  FACE. 


81 


A  sagittal  section  will  also  show  this  relationship,  and  further  that 
the  neural  tube  not  only  lies  behind  the  alimentary  tube,  but  also 


Fig.  22.— Transverse  Section  of  the  Head  End  of  an  Embryo  Twelve  Days 
Old.     A,  alimentary  tube;  N,  neural  tube;  NC,  notochord;   OP,  oral  plate. 

arches  forward  above  the  upper  end  of  the  latter  like  a  hood,  over- 
riding it  anteriorly.     This  upper  part  of  the  neural  tube,  which 


Fig.  23. — Sagittal  Section  of  the  Head  End  cf  an  Embryo  Twelve  Days 
Old.  A,  alimentary  tube;  FB,  vesicle  of  the  forebrain  overriding  the  end  of 
the  alimentary  tube;  N,  neural  tube;  NC,  notochord;  OP,  oral  plate  (site  of 
future  mouth),  which  ruptures  during  the  fourth  week. 

projects  forward  over  the  end  of  the  alimentary  tube,  is  called  the 
vesicle  of  the  forebrain. 


82  HEAD  AND  FACE. 

In  the  third  week  there  may  be  seen,  upon  either  side  of  the 
head  end  of  the  embryo,  four  transverse  plates  or  ribs  of  tissue 
which  are  separated  from  one  another  by  deep  fissures,  or  clefts. 
The  thickened  plates  are  called  visceral  arches,  and  the  intervening 
spaces,  or  fissures,  visceral  clefts.  Within  the  alimentary  tube,  upon 
its  inner  aspect,  there  may  be  seen  corresponding  arches  and  clefts. 
These  arches  are  simply  thickenings  or  ribs  in  the  lateral  walls  of 
the  head  end  ("schlund,"  pharynx)  of  the  alimentary  tube.  Each 
mass  consists  of  mesoblast,  covered  upon  its  outer  surface  by  the 
epidermic  layer,  which  covers  the  whole  exterior  of  the  body,  and 
upon  its  inner  surface  by  the  endodermic  layer,  which  lines  the 
whole  inner  surface  of  the  alimentary  tube.  Between  the  arches, 
at  the  bottom  of  any  two  opposed  clefts,  the  wall  of  tissue  is  ex- 
tremely thin;  consists  practically  of  the  outer  (epidermic)  and  the 
inner  (endodermic)  layers.  The  uppermost  of  these  visceral  arches, 
that  concerned  in  the  formation  of  the  face,  is  the  thickest.  It 
extends  forward,  and  in  front,  where  it  is  narrower,  unites  in  the 
middle  line,  with  its  fellow  of  the  opposite  side  to  form  the  mandib- 
ular arch,  which  represents  the  future  lower  jaw.  The  second  arch 
is  less  prominent  than  the  first,  and  as  it  passes  forward  is  directed 
somewhat  upward.  This  second  arch  does  not  reach  as  far  as  the 
middle  line.  The  third  and  fourth  arches  are  still  less  prominent 
and  still  shorter.  These  lower  three  arches  do  not  join  with  their 
fellows  across  the  middle  line  in  front,  but  are  continued  into  the 
plate  of  tissue  which  forms  the  front  wall  of  the  (schlund)  pharynx. 
From  above  downward  these  arches  overlap  and  partially  conceal 
each  other;  so  that  the  third  and  fourth,  especially  the  fourth,  are 
almost  entirely  concealed  by  the  first  and  second.  The  uppermost 
arch  appears  earliest.  The  appearance  of  these  arches  is  the  first 
indication  that  marks  the  commencement  of  the  formation  of  the 
face. 

Owing  to  the  progressive  growth  of  the  visceral  arches,  which 
causes  a  thickening  of  the  parts  that  immediately  adjoin  the  area 
already  mentioned  as  the  oral  plate,  and  on  account  of  the  presence 
of  the  prominent  overhanging  forebrain  vesicle  (neural  tube)  above, 
the  oral  plate  becomes  relatively  depressed,  and  we  have  thus,  in 
its  stead,  a  distinct  fossa,  which  is  called  the  oral  pit.  The  oral  pit 
is  bounded  above  by  the  overhanging  forebrain  vesicle  and  below 
and  upon  the  sides  by  the  first  visceral  arches.  These  are  the  parts 
which  immediately  surround  the  oral  pit  and  which  are  finally  de- 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  83 

veloped  into  the  face;  the  oral  pit  represents  the  future  oral  and 
nasal  cavities.   „ 

The  second,  third,  and  fourth  visceral  arches  are  not  concerned 
in  the  formation  of  the  face. 

The  next  change  noticed  in  the  parts  about  the  oral  pit  is  the 
appearance  of  a  thick,  rounded  mass  or  process  upon  the  upper  hack 
part  of  the  first  visceral  arch  of  either  side;  this  is  called  the  supe- 
rior maxillary  process.     Above,  corresponding  to  the  upper  margin 


Fig.  24.— Face  of  Embryo,  Fifth  Week.  Front  view.  E,  eye;  IM,  inferior 
maxillary  process  (first  visceral  arch)  joins  in  middle  line  with  its  fellow  of 
the  opposite  side  to  form  the  mandibular  arch  (future  lower  jaw) ;  LN,  lateral 
nasal  process  (outer  extremity  of  the  frontal  process) ;  MN,  middle  nasal 
process  (middle  portion  of  frontal  process);  NN,  nasal  notch  (future  nostril); 
SM,  superior  maxillary  process  (upper  back  part  of  the  first  visceral  arch) ; 
1,  2,  3,  first,  second,  and  third  visceral  arches. 

of  the  oral  pit,  there  appears  a  single  broad  process,  which  is  devel- 
oped by  the  forward  and  downward  growth  of  the  anterior  wall  of 
the  vesicle  of  the  forebrain;  this  is  called  the  frontal  process  or 
frontal  plate,  and  is  really  a  prolongation  of  the  front  wall  of  the 
vesicle  of  the  forebrain;  it  grows  downward  and  plays  a  very  im- 
portant role  in  the  development  of  the  face.  At  this  stage  the  oral 
pit  is  a  five-sided,  deep  fossa,  bounded  above  by  the  frontal  process 
or  frontal  plate,  below  by  the  mandibular  arch  (inferior  maxillary 
processes),  and  upon  each  side  by  the  superior  maxillary  process. 


84 


HEAD  AXD  FACE. 


The  eyes  are  located  one  upon  either  side  of  the  head,  and  are 
bounded  below  by  the  upper  back  part  of  the  superior  maxillary 
process  and  internally  by  the  outer  border  of  the  frontal  process. 

The  frontal  process,  frontal  plate,  is  broad,  and  consists  of  a 
middle  portion,  the  middle  nasal  process,  and  two  lateral  portions, 
the  lateral  nasal  processes. 


Fig.  25.— Face  of  Embryo,  Fifth  Week.  Front  view.  The  anterior  portion 
of  the  visceral  arches  has  been  cut  away  to  show  the  interior  of  the  mouth 
cavity  (pharynx),  the  wall  of  which  shows  the  visceral  arches  with  interven- 
ing clefts  corresponding  to  those  upon  the  outside.  IM,  cut  surface  of  infe- 
rior maxillary  process;  LN,  lateral  nasal  process;  8M,  superior  maxillary 
process;  1,  2,  3,  4,  cut  surface  of  the  first,  second,  third,  and  fourth  visceral 
arches,  showing  the  corresponding  clefts  between  them.  Between  LN  and 
middle  nasal  process  is  the  nasal  notch  (future  nostril). 


The  middle  nasal  process  is  quite  broad,  and  its  lower  free 
border  is  deeply  notched  in  the  middle.  The  lateral  nasal  process, 
one  on  either  end  of  the  frontal  process,  is  separated  from  the  middle 
nasal  process  by  a  deep  notch,  the  olfactory  groove;  the  floor  of 
each  olfactory  groove  is  intimately  related  with  the  base  of  the 
cerebral  vesicle:    organ  of  smell. 


CONGENITAL  DEFORMITIES  OF  THE  FACE. 


85 


During  the  fourth  week  the  plate  of  tissue  which  forms  the 
floor  of  the  oral  pit  heeomes  very  thin,  consisting  only  of  the  epider- 
mic and  endodermic  layers.  It  is  called  the  "rachenhaut  of  Kemak," 
or  the  pharyngeal  membrane,  and  during  this  week  ruptures  and  so 
establishes  a  communication  from  without  with  the  alimentary  tube 
— pharynx. 

Somewhat  later,  about  the  fifth  week,  we  find  that  the  various 
processes  have  approached  each  other,  and  the  appearance  begins 


Fig.  26.— Embryo  about  Fourth  Week,  seen  from  Side.    1,  2,  3,  4,  visceral 
arches  with  clefts  between  them. 


to  suggest  the  ultimate  conformation  of  the  face.  The  superior 
maxillary  processes  are  nearer  the  middle  line,  the  whole  frontal 
process  is  longer,  and  its  separation  into  a  middle  and  two  lateral 
portions  is  still  more  pronounced  on  account  of  the  increased  depth 
of  the  olfactory  grooves.  The  eyes  are  fairly  well  bounded,  but  are 
still  located  upon  the  side  of  the  head. 

About  the  seventh  week  we  note  that  the  superior  maxillary 
process,  in  part,  has  become  fused  with  the  lateral  nasal  process 


86  HEAD  AND  FACE. 

of  the  frontal  plate;  this  line  of  fusion  corresponds  to  the  position 
of  the  tear-duct.  If  union  does  not  occur  along  this  line,  we  have 
a  so-called  orbito-nasal  or  oblique  facial  cleft.  The  eye  is  entirely 
surrounded  and  is  placed  more  to  the  front  of  the  face.  The  middle 
portion  of  the  frontal  plate,  the  middle  nasal  process,  is  still  notched 
in  the  center  and  broad;  the  extremities  of  this  middle  nasal  process 
have  become  fused  with  the  lowest  and  most  internal  part  of  the 
superior  maxillary  process,  and  by  this  union  the  upper  lip  is  formed 


Fig.  27.— Embryo  about  Eighth  Week.    Development  of  face  well  advanced. 

and  at  the  same  time  the  olfactory  grooves  are  bounded  below,  and 
are  thus  converted  into  round  openings:  the  nostrils.  If  the  supe- 
rior maxillary  process  and  middle  portion  of  the  frontal  plate, 
middle  nasal  process,  fail  to  unite,  we  have,  as  a  result,  a  cleft  in 
the  lip, — harelip;  this  may  or  may  not  reach  into  the  opening  of 
the  nostril:  i.e.,  may  be  complete  or  incomplete  according  to  the 
extent  to  which  the  parts  have  failed  to  unite. 

The  lower  edge  of  the  superior  maxillary  process  becomes  par- 
tially united  with  the  upper  border  of  the  mandibular  process,  the 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  87 

inferior  maxillary  process,  which  has  also  become  thickened,  and 
in  this  way  the  size  of  the  mouth  is  much  diminished.  If  this  union 
falls  short  of  normal  we  have  a  characteristic  deformity:  macrostoma 
or  transverse  facial  cleft.  The  face,  as  a  whole,  is,  therefore,  at  this 
period  closed  in,  hut  the  nostrils  are  still  far  apart,  the  nose  broad, 
and  perfectly  flat  and  directed  forward,  and  the  upper  lip  is  still 
notched  in  the  middle  line.  This  type  of  face  often  persists,  and 
we  then  have  a  peculiar  "pug  face." 

The  openings  for  the  external  auditory  meatus  are  seen  low 
down  upon  either  side  of  the  head. 

The  external  auditory  canal  is  the  remains  of  the  posterior  part 
of  the  first  visceral  cleft:  i.e.,  that  between  the  first  and  second 
arches.  The  margins  of  the  orifice  of  the  auditory  canal  later  be- 
come nodulated;  these  nodules  coalesce,  and  in  this  way  the  auricle 
is  formed.  The  Eustachian  tube  and  the  tympanum  are  the  remains 
of  the  corresponding  first  internal  cleft  (from  pharynx).  The  ear- 
drum represents  the  point  where  the  epiderm,  at  the  bottom  of  the 
outer  cleft,  and  the  endoderm,  at  the  bottom  of  the  inner  cleft,  have 
coalesced  with  each  other. 

At  the  end  of  the  second  month  the  eyes  are  located  toward 
the  front  of  the  face.  The  nose  is  still  broad  and  flat,  although  the 
nostrils  are  rather  closer  together.  The  upper  lip,  representing  the 
middle  portion,  middle  nasal  process,  of  the  frontal  plate,  is  still 
notched  in  the  middle  line.  The  cavity  of  the  mouth  is  fairly  well 
closed  in  by  the  upper  and  lower  lips. 

To  recapitulate:  The  first  visceral  arch  is  eventually  developed 
into  the  inferior  maxillary  bone  and  the  adjoining  soft  parts,  includ- 
ing the  lower  lip  and  the  floor  of  the  mouth,  and  assists  in  the  forma- 
tion of  the  tongue.  The  superior  maxillary  process  of  the  first 
visceral  arch  is  developed  into  the  superior  maxillary  bone  and  the 
adjoining  soft  parts,  including  the  hard  and  soft  palate.  The  frontal 
plate,  its  lateral  portion,  the  lateral  nasal  process,  forms  the  side  of 
the  nose,  including  the  nasal  bones;  its  middle  portion,  the  middle 
nasal  process,  forms  the  bridge  of  integument  between  the  nostrils, 
reaching  from  the  tip  of  the  nose  to  the  upper  lip,  and  the  cartilagi- 
nous and  bony  portions  of  the  nasal  septum  (vomer  and  perpendicular 
plate  of  the  ethmoid);  also  the  middle  portion  of  the  upper  lip  and 
intermaxillary  bone. 

The  intermaxillary  bone  was  first  described  by  the  poet  Goethe. 
It  is  a  small,  wedge-shaped,  bony  process  which  is  attached  to  the 


88 


HEAD  AND  FACE. 


anterior  end  of  the  vomer  and  fits  into  a  corresponding  triangular 
space  in  the  anterior  part  of  the  hard  palate,  and  carries  the  four 
incisor  teeth.  The  line  of  union  between  this  bone  and  the  palatal 
processes  of  the  superior  maxillary  may  often  be  plainly  seen  in  the 
adult  upper  jaw-bone.  The  anterior  palatine  canal  marks  the  junc- 
tion of  these  parts.  A  non-united,  abnormally  placed  intermaxillary 
bone  often  complicates  harelip. 


Fig.  28.— Face  of  Embryo  about  Eighth  Week.  The  various  processes  that 
go  to  make  up  the  face  have  coalesced,  but  the  embryonal  type  of  the  face  is 
still  well  marked.  Eyes  located  upon  the  side  of  face.  Ears  low  down.  Nose 
flat  and  projecting  forward,  with  nostrils  far  apart.  Upper  lip  still  notched 
in  the  middle. 


Formation  of  the  Palate. — The  superior  maxillary  process  of 
either  side  gives  off,  upon  its  inner  aspect,  a  shelf -like  process:  the 
palate  process.  These  processes  gradually  grow  toward  the  middle 
line  and  unite  with  each  other,  and  thus  form  the  hard  and  soft 
palate,  the  union  taking  place  from  before  backward,  the  uvula  being 
the  last  part  to  unite.    Union  between  the  palatal  processes  is  com- 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  89 

plete  at  about  the  eleventh  week.  With  the  formation  of  the  hard 
and  soft  palate,  the  nasal  cavity  is  separated  from  the  oral,  or  mouth, 
cavity.  Failure  of  union  between  the  palatal  processes  gives  rise 
to  the  various  degrees  of  cleft  palate.  In  front,  where  the  two  halves 
of  the  hard  palate  join  with  the  intermaxillary  bone,  there  are  a 
suture  line  and  the  anterior  palatine  canal. 

The  vomer  and  the  perpendicular  plate  of  the  ethmoid  are  de- 
veloped from  the  middle  portion — the  middle  nasal  process — of  the 
frontal  plate,  and  divide  the  nasal  cavity  into  two  parts.  The  junc- 
tion between  the  lower  border  of  the  vomer  and  the  hard  palate 
occurs  after  the  two  palatal  processes  have  united  with  each  other 
in  the  middle  line.  The  nasal  cavity  opens  in  front  upon  the  face 
through  the  nostrils  and  behind  into  the  pharynx  through  the  poste- 
rior nares. 

The  Teeth. — The  margins  of  the  upper  and  lower  jaw  become 
prominent,  and  in  this  way  form  the  alveolar  processes;  the  epithe- 
lium covering  these  processes  becomes  invaginated, — dips  down  into 
the  substance  of  the  processes, — and  from  this  the  teeth  are  formed. 

The  floor  of  the  mouth  is  developed  from  the  first  visceral  arch. 

The  Tongue. — The  tongue  is  developed,  its  anterior  portion  from 
the  first  arch  and  its  posterior  portion  from  the  second  and  third 
arches.  The  anterior  part — the  body  and  tip — is  developed  from  a 
tubercle  which  appears  in  the  front  part  of  the  mouth  at  the  junction 
of  the  two  halves  of  the  first  arch.  The  back  part,  the  root,  is  devel- 
oped in  the  back  part  of  the  mouth  from  the  wall  of  the  pharynx, 
from  two  tubercles  at  the  junction  of  the  second  and  third  arches. 
These  two  parts  of  the  tongue,  the  anterior  and  the  posterior,  become 
joined,  the  line  of  union  being  indicated  by  the  V-shaped  row  of 
papilla?  upon  the  dorsum  of  the  adult  tongue.  At  the  apex  of  the  V 
there  is  a  dimple,  the  foramen  cascum,  which  indicates  the  point  of 
junction  of  the  parts  of  which  the  tongue  is  formed.  As  the  tongue 
is  developed,  it  increases  rapidly  in  size,  occupying  the  mouth  cavity 
and  projecting  up  into  the  future  nasal  cavity.  As  the  palatal 
processes  grow  inward  to  meet  each  other  in  the  middle  line,  how- 
ever, the  tongue  is  gradually  forced  down  into  the  mouth  cavity 
proper,  where  it  belongs. 

Deformities  of  the  Face. — These  consist  of  abnormal  clefts  and 
atresias,  which  may  be  partial  or  complete. 

Clefts  are  due  to  the  entire  or  partial  absence  of  normal  union 
between  the  original  embryonal  processes  by  whose  coalescence  the 


90 


HEAD  AND  FACE. 


face  is  formed.  Atresias  are  caused,  on  the  other  hand,  by  excessive 
union,  beyond  the  normal,  between  these  processes,  and  as  a  result 
we  get  a  partial  or  complete  closure  of  the  facial  orifices:  mouth, 
nostrils,  and  eyes.  Still  further,  the  union  between  the  processes 
may  occur  to  its  normal  extent,  but  the  lines  of  union  may  remain 
permanently  marked  by  cicatricial  seams  or  irregular  tags  and 
nodules. 

The  failure  of  the  embryonal  processes  properly  to  coalesce, 


Fig.  29.— Diagram  of  Congenital  Facial  Clefts.  Shaded  portions  indicate 
the  location  of  the  different  congenital  fissures.  HL,  harelip;  IM,  inferior 
maxillary  process;  LN,  *,  lateral  nasal  process  of  frontal  plate;  LN,  lateral 
nasal  cleft;  M.N.,  middle  nasal  process  of  frontal  plate;  OF,  oblique  facial 
cleft;  SM,  superior  maxillary  process;  TF,  transverse  facial  cleft;  *,  lower 
part  of  lateral  nasal  process  which  takes  part  in  the  formation  of  the  upper 
lip,  but  not  of  its  red  border;  the  free  red  margin  of  the  lip  is  formed  by  the 
union  of  the  lower  part  of  the  middle  nasal  process  (MN)  and  the  lower 
part  of  the  superior  maxillary  process  {SM). 


with  the  resulting  clefts,  is  really  due  to  the  incomplete  develop- 
ment of  the  processes  themselves;  they  are  deficient:  i.e.,  too  small 
to  meet  each  other,  and  hence  the  clefts.  The  clefts  vary  in  degree 
from  narrow,  incomplete  fissures  to  widely  gaping  spaces.  The  mar- 
gins of  the  clefts  may  be  smooth  or  they  may  be  irregular  and  marked 
by  nodular  processes,  tags,  etc. 

The  congenital  deformities  of  the  face  may  be  divided  into  two 
general  groups: — 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  91 

(A)  Those  in  which  the  frontal  plate  or  process  is  concerned. 
Under  this  heading  we  have: — 

1.  Lateral  clefts  of  the  upper  lip  and  the  alveolar  process;  clefts 
of  the  palate  may  also  be  conveniently  included  in  this  group. 

2.  Median  clefts  or  notches  of  the  upper  lip  and  deformities  of 
the  nose. 

3.  Notching  of  the  wing  of  the  nose. 

4.  Oblique  facial  fissures,  etc. 

(B)  Those  in  which  the  first  visceral  arch  is  involved.  In  this 
group  we  have: — 

1.  Transverse  facial  fissures. 

2.  Median  fissures  of  the  lower  lip,  lower  jaw,  and  tongue. 

3.  Deformities  of  the  lower  jaw. 

Deformities  in  Which  the  Frontal  Plate  is  Concerned.  Lateral 
Clefts  of  the  Upper  Lip  and  of  the  Alveolar  Process  and 
Cleft  Palate. — Clefts  of  the  upper  lip  and  alveolar  process  depend 
upon  imperfect  union  of  the  middle  portion,  middle  nasal  process, 
of  the  frontal  plate  with  the  corresponding  lower  portion  of  the 
superior  maxillary  processes:  to  failure  of  the  intermaxillary  bone 
and  its  accompanying  soft  parts  to  unite  with  the  adjoining  portion 
of  the  face.  These  clefts  are  always  lateral  and  may  be  present  on 
one  or  both  sides.  Clefts  of  the  palate  (hard  and  soft)  depend  upon 
non-union,  partial  or  complete,  of  the  palatal  process  of  the  superior 
maxillary  process  of  either  side  with  each  other.  These  clefts  are 
median  when  the  processes  of  both  sides  are  at  fault.  If  the  palatal 
process  of  one  side  only  is  involved,  the  fissure  will  be  present  upon 
the  corresponding  side  of  the  middle  line,  the  palatal  process  of  the 
other  side  being  joined  with  the  lower  border  of  the  vomer,  thus 
shutting  off  the  nasal  cavity,  on  that  side,  from  the  mouth. 

If  union  has  failed,  on  both  sides,  between  the  middle  process  of 
the  frontal  plate,  the  middle  nasal  process,  and  the  corresponding  part 
of  the  superior  maxillary  process  of  either  side  (double  harelip  and  fis- 
sure of  the  alveolar  process)  and  between  the  palatal  processes  of  the 
superior  maxillary  processes  of  either  side  (cleft  of  the  hard  and  soft 
palate),  we  have  the  most  extreme  variety  of  this  group  of  deformi- 
ties. There  are  found  all  degrees  of  this  variety  of  deformity  from 
this  exaggerated  form  down  to  a  mere  notching  of  the  upper  lip 
(incomplete  harelip)  or  bifurcation  of  the  uvula. 

Harelip. — This  condition  may  be  incomplete  or  complete. 

Incomplete  harelip  consists  in  a  vertical  notch  in  the  free  mar- 


92  HEAD  AND  FACE. 

gin  of  the  upper  lip.  It  is  located  to  one  side  of  the  middle  line 
between  the  middle  segment  and  the  lateral  segment  of  the  lip.  It 
varies  in  depth  from  a  barely  noticeable  notch  to  a  deep  fissure 
which  may  extend  almost  through  the  entire  lip,  leaving  but  a  nar- 
row bridge  of  integument  separating  the  angle  of  the  notch  from 
the  nostril. 

In  complete  harelip  the  fissure  extends  all  the  way  through  the 
upper  lip  into  the  nostril.  It  may  be  associated  with  cleft  of  the 
alveolar  process  and  with  cleft  palate.  The  nose  is  apt  to  be  un- 
usually broad  and  flattened,  the  wing  of  the  nose,  on  the  side  corre- 
sponding to  the  cleft,  being  carried  outward  away  from  the  middle 
line.     These  deformities  may  involve  one  or  both  sides.    If  double, 


Fig.  30.— Double  Complete  Harelip. 

those  of  the  two  sides  may  differ  from  each  other,  the  fissure  on  one 
side  may  be  complete,  that  of  the  other  side  incomplete,  or  those  of 
both  sides  may  be  complete.  They  may  be  associated  with  cleft  of 
the  alveolar  process  and  with  cleft  palate,  the  intermaxillary  bone 
often  being  small  and  misplaced  forward.  The  entire  middle  seg- 
ment of  the  lip  may  be  absent,  together  with  the  intermaxillary  bone 
and  the  vomer.  In  this  case  the  upper  lip  shows  a  broad,  median 
space,  which  opens  into  the  nasal  cavity. 

Cleft  of  the  Alveolar  Process. — With  harelip,  as  already  men- 
tioned, there  may  also  be  present  a  cleft  of  the  alveolar  process, 
and  this  may  vary  from  a  narrow,  incomplete  fissure  to  a  broad,  open 
space;  it  may  be  unilateral  or  double,  and  is  usually  associated  with 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  93 

cleft  palate.  If  there  is  no  cleft  of  the  hard  palate,  the  cleft  of  the 
alveolar  process  terminates  at  the  anterior  palatine  foramen:  the 
meeting  point  of  the  palatal  process  of  either  side  and  the  inter- 
maxillary bone.  If  the  cleft  in  the  alveolar  process  involves  both 
sides,  the  intermaxillary  bone,  which  is  continuous  with  the  front 
of  the  vomer,  may  be  placed  forward  in  advance  of  the  rest  of  the 
alveolar  process,  especially  if  cleft  palate  is  also  present;  so  that  it 
and  the  corresponding  portion  of  the  upper  lip  seem  to  be  suspended 
from  the  point  of  the  nose.  In  this  case  the  lower  tegumentary  part 
of  the  septum  of  the  nose  is  absent,  the  soft  parts  which  represent 
the  middle  part  of  the  lip  being  continued  directly  with  the  tip  of 
the  nose.    This  advancement  of  the  intermaxillary  bone  is  due  to  the 


Fig.  31.— Harelip  with  (A)  Advanced  Intermaxillary  Portion. 

unrestricted  forward  growth  of  the  vomer,  which  is  not  inhibited  as 
is  normally  the  case  when  it  is  joined  to  the  palatal  processes.  If 
the  cleft  is  confined  to  one  side  of  the  alveolar  process  and  the  hard 
palate,  the  intermaxillary  bone,  as  it  is  carried  forward  by  the  growth 
of  the  vomer,  is  apt  to  become  markedly  twisted  upon  its  long  axis, 
so  that  its  anterior  surface,  instead  of  being  directed  forward,  looks 
almost  directly  toward  the  normal  side  of  the  face,  presenting  its 
prominent  sharp  lateral  edge  anteriorly.  The  intermaxillary  seg- 
ment may  be  entirely  absent,  as  already  mentioned. 

Cleft  Palate. — The  presence  of  a  longitudinal  fissure  which  may 
involve  the  hard  or  soft  palate  or  both.  It  is  caused  by  a  failure 
of  the  palatal  processes  of  the  superior  maxillary  processes  to  meet 


94 


HEAD  AND  FACE. 


in  the  middle  line  and  coalesce.  In  these  cases  the  hase  of  the 
skull  may  be  unusually  broad  and  the  pterygoid  processes  unusually 
far  apart. 

Cleft  of  the  Hard  Palate.— This  may  be  unilateral  or  double. 
If  one-sided,  the  palatal  process  of  the  normal  side  is  seen  to  be 
united  with  the  lower  border  of  the  vomer,  shutting  off  that  side 
of  the  nasal  cavity  from  the  mouth,  while  upon  the  affected  side 
the  palatal  process  is  deficient  and  falls  short  of  meeting  its  fellow 
of  the  opposite  side,  and  there  is  thus  left  an  opening  which  leads 
into  the  corresponding  half  of  the  nasal  cavity.  In  double  cleft 
palate  both  palatal  processes  are  deficient,  and  the  lower  free  edge 
of  the  vomer  may  be  seen  between  the  separated  edges  of  the  cleft. 


Fig.  32.— Double  Cleft  Palate  with  Advanced  Intermaxillary  Portion  (IM) 
Carrying  the  Sockets  of  Two  Incisor  Teeth.  V,  vomer  (septum  of  the 
nose). 


Usually  the  lower  border  of  the  vomer  does  not  reach  low  enough 
to  present  itself  in  the  fissure  between  the  edges  of  the  cleft,  and 
the  cleft  thus  has  the  appearance  of  a  median  cleft  when  it  is,  in 
reality,  a  bilateral,  or  double,  cleft. 

At  times  we  may  find  the  palatal  processes  of  either  side  prop- 
erly united  with  each  other,  but  the  vomer  fails  to  grow  down  suffi- 
ciently far  to  articulate  with  them,  and  there  is  thus  left  a  space 
below  the  lower  border  of  the  vomer  through  which  the  two  sides  of 
the  nasal  cavity  communicate  with  each  other.  It  should  be  remem- 
bered that  the  vomer  does  not  play  any  part  in  the  formation  of  the 
hard  palate. 

Cleft  of  the  hard  palate  ends  anteriorly,  either  at  the  anterior 


CONGENITAL  DEFORMITIES  OF  THE  FACE.  95 

palatine  foramen,  which  marks  the  point  of  junction  between  the 
intermaxillary  bone  and  the  palatal  processes  of  the  superior  maxil- 
laries,  or  else  it  is  combined  with  a  single  or  double  cleft  of  the 
alveolar  process  and  harelip.  It  usually  ends,  posteriorly,  in  cleft 
of  the  soft  palate. 

In  cleft  palate,  especially  if  double,  the  forward  growth  of  the 
vomer  is  unrestricted  on  account  of  its  not  being  joined  to  the 
palatal  processes,  and  by  this  forward  growth  the  intermaxillary 
bone  and  its  corresponding  soft  parts  may  be  carried  forward  beyond 
the  line  of  the  alveolar  processes,  the  intermaxillary  bone  often  being 
bent  upward  or  twisted  upon  its  long  axis  (see  Fig.  32).  This  ad- 
vancement of  these  parts  adds  very  much  to  the  difficulty  of  cor- 
recting the  deformity. 

Cleft  of  the  Soft  Palate. — The  fissure  extends  from  the  tip  of  the 
uvula  for  a  varying  distance  into  the  soft  palate.  It  may  be  simply 
a  bifurcation  of  the  uvula,  but,  as  a  rule,  it  extends  all  the  way 
through  the  soft  palate  as  far  as  the  posterior  border  of  the  hard 
palate  or  for  some  distance  into  the  hard  palate.  It  may  be  com- 
bined with  a  lateral  or  double  cleft  of  the  hard  palate.  As  is  the 
case  with  cleft  of  the  hard  palate,  there  is  not  only  a  simple  lack 
of  union  between  the  two  halves  of  the  palate,  but  an  actual  defi- 
ciency of  tissue  which  prevents  the  parts  from  meeting  and  coalescing 
in  the  middle  line,  and  this  fact  is  important  in  considering  the 
operative  treatment  of  this  condition. 

With  the  exaggerated  forms  of  cleft  palate  there  is  frequently 
associated  imperfect  development  of  the  middle  nasal  process  of  the 
frontal  plate  or  it  may  be  entirely  absent:  the  intermaxillary  bone 
may  be  absent,  with  or  without  absence  of  the  vomer.  If  the  inter- 
maxillary bone,  etc.,  are  absent,  we  have  a  median  cleft  of  the  upper 
lip,  or,  better,  a  double  harelip  with  absence  of  its  middle  segment; 
and  this  condition  is  usually  associated  with  a  broad  cleft  in  the 
hard  and  soft  palate,  and  the  nose  may  be  soft  and  flattened,  on 
account  of  the  absence  of  the  nasal  septum,  etc.  This  condition 
is  apt  to  be  accompanied  with  defective  cerebral  development. 

Median  Clefts  and  Notches  of  the  Uppee  Lip. — These  de- 
formities depend  upon  exaggeration  and  persistence  of  the  embryonal 
notch  of  the  middle  portion,  the  middle  nasal  process,  of  the  frontal 
plate  and  failure  of  the  nostrils  to  approach  each  other.  These 
defects  are  much  less  frequent  than  the  preceding.  There  may  be 
simply  a  notch  or  fissure  in  the  middle  of  the  upper  lip  reaching  part 


96  HEAD  AND  FACE. 

way  through,  or  this  may  be  combined  with  a  grooving  or  furrow  upon 
the  point  and  dorsum  of  the  nose  and  a  wide  separation  between 
the  nostrils.  This  condition  may  be  so  pronounced  that  the  nose 
appears  to  consist  of  two  halves  completely  separated  from  each 
other  and  each  containing  one  nostril.  Instead  of  this  extreme 
degree  of  deformity  the  nose  may  be  simply  flattened,  the  bridge  de- 
pressed, the  nostrils  far  apart  and  looking  directly  forward:  "dog 
nose."  The  fissure  in  the  upper  lip  instead  of  simply  notching  the 
lip  may  extend  completely  through  the  whole  lip  and  into  the  inter- 
maxillary bone.  This  variety  of  deformity  may  also  be  represented 
by  a  fistula  of  the  tip  or  dorsum  of  the  nose. 

Latekal  Nasal  Clefts. — These  occur  with  or  without  harelip 
and  cleft  palate;  the  notch  or  fissure  involves  the  wing  of  the  nose. 
If  they  extend  upward  for  a  considerable  distance  through  the  side 


Fig.  33.— Oblique  Facial  Cleft  Extending  into  the  Temporo-frontal  Region. 

of  the  nose,  they  terminate  above,  not  in  the  inner  canthus,  but  to 
the  inner  side  of  the  inner  corner  of  the  eye;  they  represent  the 
embryonal  notch  between  the  middle  and  lateral  nasal  processes  of 
the  frontal  plate.  Fissures  of  the  side  of  the  nose,  that  resemble 
these,  but  terminate  above  in  the  inner  canthus  of  the  eye,  are 
varieties  of  oblique  facial  clefts. 

Oblique  Facial  Clefts. — Failure  of  normal  union  between  the 
lateral  process  of  the  frontal  plate  and  the  superior  maxillary  process 
of  the  first  visceral  arch.  They  correspond  to  the  embryonal  orbito- 
nasal line  of  coalescence.  These  deformities  may  be  very  extensive 
or  slight:  one-sided  or  double.  They  commence  below  at  the  edge 
of  the  upper  lip,  and,  after  splitting  this  at  the  usual  harelip  site, 
extend  upward  through  the  cheek,  alongside  of  the  wing  of  the  nose, 


CONGENITAL  DEFORMITIES  OF  THE  FACE. 


97 


not  into  the  nostril,  like  harelip,  and  terminate  above,  at  the  lower 
margin  of  the  eye  (lower  lid)  or  inner  canthus.     They  may  extend 


Fig.  34.— Incomplete  Oblique  Facial  Cleft.  The  edge  of  the  upper  lip  is 
notched  and  a  cicatricial  line  extends  across  the  cheek  to  the  lower  eyelid, 
which  is  everted. 

beyond  the  orbit,  from  its  outer  corner,  upward  and  outward  into 
the  fronto-temporal  region  of  the  skull.    They  vary  from  a  narrow. 


Fig.  35.— Transverse  Facial  Cleft. 


fissure  or  incomplete  notch  to  a  wide,  gaping  fissure,  between  the 
edges  of  which  is  the  eyeball.    This  class  of  deformity  is  frequently 


98  HEAD  AND  FACE. 

represented  in  its  simplest  form  by  a  notch  or  coloboma  of  the  lower 
or  upper  eyelid.  Instead  of  a  fissure,  this  deformity  may  be  repre- 
sented by  a  cicatricial,  nodulated  seam,  indicating  the  orbito-nasal 
junction. 

Deformities  in  Which  the  First  Visceral  Arch  is  Concerned. 
Teansveese  Facial  Clefts,  etc. — These  are  due  to  a  failure  of 
the  inferior  maxillary  process  of  the  first  visceral  arch  and  its  supe- 
rior maxillary  process  to  coalesce  to  the  normal  extent.  This  de- 
formity may  be  unilateral  or  double.  The  cleft  extends  from  the 
corner  of  the  mouth  outward  through  the  cheek  and  exposes  the 
teeth:  macrostoma.  If  the  reverse  of  this  process  occurs,  we  may 
have  a  mouth  so  small  as  to  require  surgical  interference:  micro- 
stoma. 

Median  Clefts  of  the  Lowee  Lip,  Lowee  Jaw,  and  Tongue. 
— These  conditions  are  very  rare.  They  are  due  to  failure  of  the 
two  halves  of  the  first  visceral  arch  (mandibular  processes)  to  unite 
with  each  other  in  the  middle  line.  They  vary  from  a  slight  notch- 
ing of  the  lower  lip,  in  the  middle  line,  to  a  complete  separation 
through  the  lower  lip,  the  lower  jaw  at  the  symphysis,  and  the 
tongue.  The  tongue,  by  itself,  may  be  split  or  absent  or  bound  down 
to  the  floor  of  the  mouth  or  adherent  to  the  side  of  the  cheek,  etc. 

The  lower  jaw  may  be  imperfectly  developed,  rudimentary,  etc. 
It  may  be  split  in  the  middle  line  or  there  may  be  absence  of  the 
condyles,  etc.  As  the  formation  of  the  face  advances  the  jaw  is 
gradually  protruded  forward,  and,  if  arrested,  we  have,  as  a  result, 
the  receding  chin,  etc. 

OPERATIONS  FOR  HARELIP  AND  CLEFT  PALATE,  ETC. 

Operations  for  Harelip. — In  speaking  of  harelip — if  single — the 
flap  corresponding  to  the  angle  of  the  mouth  is  called  the  lateral 
flap,  or  segment,  and  the  other,  the  middle;  if  the  harelip  is  double, 
one  speaks  of  the  middle  segment  and  two  lateral  segments,  the  right 
and  the  left. 

Koenig  advocates  early  operation,  within  a  few  days  after  birth. 
Trendelenburg  advises  delaying  the  operation  until  later,  operating 
between  the  third  and  sixth  months,  and,  if  very  complicated,  waiting 
still  longer.  Trendelenburg  claims  that  the  difficulty  in  nourishing 
the  children  is  not  a  good  ground  for  early  operation;  that  children, 
even  with  a  cleft  palate  in  addition  to  the  harelip,  can  feed  from 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC.  99 

a  bottle  if  it  is  provided  with,  a  nipple  attached  to  the  neck  of  the 
bottle  itself,  and  especially  if  the  child  is  assisted  by  the  nurse 
holding  the  bottle.  If  the  child  is  able  to  take  the  breast  it  will 
not  be  necessary  to  change  to  the  bottle  after  operation  and  the 
breast  nursing  may  still  be  continued.  At  the  time  of  operation  the 
child  should  be  free  from  intestinal  trouble,  and  there  should  be 
little  or  no  nasal  catarrh. 

For  children  under  one  year  no  anaesthetic  is  necessary;  for 
older  children  one  may  use  incomplete  chloroform  anaesthesia. 

The  child  should  be  wrapped  in  a  blanket  in  such  a  way  that 
the  arms  and  legs  are  confined  and  then  held  upright  in  the  arms 
of  a  nurse  who  sits  opposite  the  operator.  The  child's  head  is 
steadied  by  an  assistant,  who  thrusts  the  head  a  little  forward  to 
prevent  the  blood  entering  the  mouth  during  the  operation. 

The  instruments  that  are  required  consist  of  a  sharp,  narrow- 
bladed  knife  with  a  sharp  point,  several  tenacula,  mouse-tooth 
forceps,  and  narrow-bladed  sharp-edged  scissors.  The  steps  of  the 
operation  consist  in  freshening  the  edges  of  the  cleft  and  suturing. 
In  freshening  the  edges  one  should  cut  with  a  view  to  providing 
broad,  raw  surfaces  for  apposition;  they  should  be  cut  somewhat 
obliquely,  and  more  taken  away  from  the  skin  than  from  the  mu- 
cous surface.  During  this  step  of  the  operation  the  hemorrhage 
may  be  controlled  by  an  assistant,  who  compresses  either  segment 
of  the  lip  between  the  finger  and  thumb,  or  a  clamp  may  be  applied 
on  either  side  of  the  defect  in  the  lip  (Trendelenburg).  With  the 
mouse-tooth  forceps  the  edge  of  the  defect  is  seized  and  transfixed 
with  a  knife,  and  the  incision  made  with  a  sawing  motion  and  with 
deliberation.  In  order  to  bring  the  raw  surfaces  into  apposition  it 
is  occasionally  necessary  to  liberate  the  flaps,  by  cutting  them  free 
from  their  attachment  to  the  deeper  adjoining  parts:  the  alveolar 
process  and  anterior  surface  of  the  superior  maxilla. 

As  suture,  several  harelippins  may  be  used,  each  with  a  figure-of- 
eight  coil  of  silk  floss.  Without  these  pins,  or  in  addition  to  them,  one 
may  unite  the  raw  surfaces  with  one  to  three  heavier  silk  sutures  car- 
ried in  a  straight  or  curved  needle.  These  should  penetrate  deep 
into  the  substance  of  the  lip,  down  to,  but  not  through,  the 
mucous  membrane,  and  should  take  a  good  hold.  Between  these 
the  skin  and  mucous  membrane  are  brought  accurately  together, 
edge  to  edge,  with  a  number  of  superficial  sutures  of  rather  finer 
silk. 


100 


HEAD  AND  FACE. 


Operations  for  Incomplete  Harelip.  Simple  Freshening  of 
the  Opposing  Edges  and  Suture. — This  plan  would  not  answer 
even  for  incomplete  harelip,  since  a  notch  would  remain  which 
would  increase  with  time  as  the  scar  contracts,  especially  if  the 
cleft  is  deep. 


I    (( 


Fig.  36.— Simple  Paring  of  the  Edges  of 
the  Notch  for  Incomplete  Harelip. 


-riYff'f 


Fig.  37.— Imperfect  Result  After  Sim- 
ple Paring  and  Suture,  Showing  the 
Notch  still  Present. 


Von  Graefe  proposed  a  very  simple  method  to  increase  the 
length  of  the  apposed  edges  of  the  freshened  surfaces.  This  method 
will  answer,  however,  only  for  the  very  incomplete  defects,  and  not 
for  wide  or  complete  splits.  It  consists  in  paring  the  edges  of  the 
notch  by  making  a  circular  incision,  which  arches  over  the  corner  of 
the  notch. 


Fig.  38.— Von  Graefe  Method  of  Paring 
an  Incomplete  Harelip  so  as  to  Increase 
the  Length  of  the  Raw  Apposed  Edges. 


Fig.  39.— Result  After  Suturing. 


Nelaton  Method. — Without  removing  any  tissue,  an  incision 
is  made  through  the  substance  of  the  lip,  around  the  corner  of  the 
cleft  and  parallel  with  its  edges,  and  after  converting  this  incision 
into  a  vertical  one  its  edges  are  united  with  several  interrupted 
stitches. 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC. 


101 


Fig.  40.— Nelaton  Opera-  Fig.  41.  —  Incision  Con- 
tion  for  Incomplete  Hare-  verted  into  a  Perpendicu- 
lip.      Line   of    incision.  lar,   ready  for  Suture. 


Fig.     42.  —  Result     After 
Suture. 


Malgaigne  proposed  to  close  the  defect,  especially  where  the 
defect  is  considerable,  by  making  use  of  flaps  in  addition  to  fresh- 
ening the  edges.  In  his  operation  the  tissue  is  removed  from  the 
angle  of  the  defect  only,  the  second  part  of  the  operation  consisting 
in  the  formation  of  flaps  by  simply  cutting  into  the  substance  of 
the  lip  along  either  side  of  the  defect,  commencing  near  the  angle 
and  cutting  toward  the  red  border  of  the  lip.    The  base  of  the  flap 


^Yv  ()J, ./»""' u  ^jTvr.i,,^ 


Fig.  43.— Malgaigne  Oper-        Fig.    44.  —  Flaps    Turned  Fig.     45.  —  Result     After 

ation  for  Incomplete  Hare-     Down,     ready    for     Suture.        Parts    have    been    Sutured, 
lip.     Paring  and   formation 
of  flaps. 

should  be  no  thicker  than  the  red  of  the  lip;  otherwise  it  is  very 
difficult  to  turn  it  down.  The  tongues  of  tissue  thus  marked  out 
are  turned  down  and  sutured  together,  with  the  result  that  the  cleft 
is  not  only  filled  in,  but  a  little  tongue  of  tissue  is  left  projecting 
beyond  the  free  line  of  the  lip  to  allow  for  future  retraction. 

The  objection  to  this  operation  is  that,  on  account  of  the  con- 
siderable torsion  to  which  the  flaps  are  subjected,  their  nourishment 
is  uncertain  and  they  may  become  gangrenous,  especially  in  very 
young  children. 


102 


HEAD  AND  FACE. 


Mirault's  operation  is  an  improvement  on  Malgaigne's.  Only 
one  flap  is  made,  and  that  is  taken  from  the  edge  of  the  lateral 
segment.  The  flap  which  is  thus  formed  is  sutured  to  the  freshened 
edge  of  the  middle  segment.  This  single  flap  is  not  likely  to  become 
gangrenous  as  is  the  Malgaigne,  because  it  is  not  necessary  to  turn 
it  down  so  far,  and,  secondly,  because  its  base  may  be  made  suffi- 
ciently broad  to  include  the  coronary  vessels.  In  forming  the  flap 
a  single  cut  is  made  into  the  substance  of  the  lip  proper,  striking 
well  above  the  red  margin  so  that  the  base  of  the  flap  corresponds 
to  the  lower  third  of  the  breadth  of  the  lip.  This  is  a  very  satis- 
factory operation.  It  has  been  modified  by  Simon,  Koenig,  Esmarch, 
Hagedorn,  and  others. 


Fig.    46.— Mirault    Opera-     Fig.    47. 
ation  for  Incomplete  Hare- 
lip.    Paring  and  formation 
of  one  flap. 


-  Parts   ready   for 
Suture. 


Fig.    48.— Result   After   Su- 
ture. 


Operations  for  Complete  Harelip.  —  Cases  in  which  the  split 
extends  through  the  entire  width  of  the  lip. 

In  these  cases  it  is  not  only  necessary  to  freshen  and  prepare 
the  edges  for  suture,  but  one  must,  in  addition,  detach  the  soft 
parts,  in  order  that  the  raw  surfaces  may  be  brought  together  and 
sutured;  one  must  unite  the  whole  width  of  the  lip  from  the  nasal 
opening  down  to  its  free  border,  and  further  strive  to  correct  the 
accompanying  nasal  deformity.  It  usually  suffices  to  separate  the 
outer  or  lateral  segment,  that  nearer  the  corner  of  the  mouth,  from 
its  attachment  to  the  superior  maxillary  bone.  Only  in  extreme 
cases  does  it  become  necessary  to  detach  the  other  flap  as  well.  To 
separate  the  flap  from  the  underlying  bone  one  seizes  its  edge  with 
a  mouse-tooth  forceps,  and  draws  it  inward  toward  the  middle  line, 
and  forward,  away  from  its  attachment  to  the  bone.  In  this  way  the 
fold  of  the  mucous  membrane  which  attaches  the  lip  to  the  gum  is 


OPERATIONS  FOE,  HARELIP,  CLEFT  PALATE,  ETC. 


103 


put  upon  the  stretch,  and  may  be  incised  with  the  edge  of  the  knife, 
cutting  toward  the  bone  (superior  maxillary).  This  incision  is  car- 
ried sufficiently  far  and  deep  to  liberate  the  lateral  flap  and  the 


Fig.  49. — Wellenschnitt  for  Complete  Harelip.  Incision,  carried  around  the 
alse  of  the  nose  in  order  to  liberate  the  segments.  Formation  of  flaps  by  in- 
cision into  each  segment. 

corresponding  side  of  the  nose  and  to  allow  of  the  parts  being  readily 
apposed  without  tension.  Hemorrhage  from  this  incision  is  often 
considerable,  especially  if  it  is  necessary  to  cut  deep,  and  this  is 
given  as  one  of  the  reasons  for  waiting  in  these  cases,  at  any  rate, 
until  the  third  or  fourth  month  (Trendelenburg).  This  hemorrhage, 
however,  usually  ceases  when  the  sutures  are  inserted  and  compres- 
sion applied;  still,  any  spurting  vessels  that  are  to  be  seen  should  be 
clamped  aud  ligated  with  fine  catgut. 

Occasionally,  in  order  to  free  the  flap  sufficiently  it  may  be 
necessary  to  make  an  incision  around  the  wing  of  the  nose;  this, 
however,  is  but  seldom  necessary  (Dieffenbach's  Wellenschnitt).  The 
Mirault  or  the  Hagedorn  operation  is  usually  done  for  this  condition 
of  complete  harelip. 


Fig.   50.— Hagedorn   Oper-     Fig.    51.  —  Parts   Freshened 
ation    for    Single    Complete         and  Ready  for  Suture. 
Harelip.     Lines  of  incision. 


Fig.    52.— Result   After   Su- 
ture. 


Hagedorn's  operation  consists  in  paring  away  the  edges  of  each 
flap,  first  from  the  margin  of  the  lateral  flap, — that  nearer  the  angle 
of  the  mouth, — and  then  from  the  margin  of  the  other  flap.     A 


104  HEAD  AND  FACE. 

horizontal  incision  is  then  made  into  the  substance  of  the  lateral 
flap  and  an  oblique  one  into  the  median  flap.  Then,  with  a  scissors, 
the  long  strips  of  vermilion  border  which  have  been  pared  away  from 
the  edges  of  the  flaps  are  snipped  off.  When  the  parts  are  sutured 
there  is  left  a  little  process  hanging  from  the  edge  of  the  lip;  this 
retracts  in  time. 

Operation  for  Single,  Complete  Harelip  Associated  with  Cleft  of 
the  Alveolar  Process  and  Advancement  of  the  Intermaxillary  Bone. 
— In  these  cases  the  intermaxillary  bone,  besides  being  misplaced, 
may  be  rotated  upon  its  long  axis  in  such  a  way  that  it  presents, 
anteriorly,  a  prominent,  sharp  edge,  which  would  greatly  interfere 
with  the  healing  process. 

Under  these  circumstances  it  becomes  necessary  to  place  the 
bone  in  its  natural  position.  An  effort  should  be  made,  by  twisting 
it  upon  its  long  axis,  to  set  it  square  so  that  its  sharp,  lateral  edge 
will  not  project  under  the  suture  line.  If  necessary,  with  the  bone 
forceps  or  the  chisel  the  process  may  be  separated  forcibly  from  its 
attachment  to  the  alveolus  and  brought  into  position  by  rotating  it 
partly  upon  its  long  axis.  The  vomer,  to  the  front  of  which  the 
intermaxillary  is  joined,  may  prevent  this  replacement,  and  then  it 
may  be  wise  to  resect  the  prominent  edge  of  the  intermaxillary  with 
a  chisel  or  rongeur,  but  if  we  do  this  we  lose  an  incisor  tooth.  These 
measures  complicate  the  operation  and  occasion  considerable  hemor- 
rhage, and  therefore  it  is  often  well,  with  this  condition,  to  defer  the 
operation  in  very  young  children.  After  the  intermaxillary  bone 
has  been  reduced  or  resected,  closure  of  the  split  in  the  lip  may  be 
accomplished  by  any  of  the  methods  described  above. 

Operation  for  Double  Harelip  without  a  Prominent  Advanced 
Intermaxillary  Bone. — The  middle  segment  is  always  found  to  be 
too  short  to  take  part  in  the  formation  of  the  free  border  of  the  lip, 
but  it  may  be  used  to  form  the  middle  portion  of  the  lip.  From  the 
whole  of  the  middle  segment  and  from  each  lateral  segment  in  part, 
the  mucous  membrane  edge  is  trimmed  away,  and  a  Malgaigne  flap 
then  made  from  the  edge  of  each  lateral  segment.  One  side  may  be 
done  at  a  sitting,  or  one  may,  by  freshening  the  lateral  margins  of 
the  middle  segment  and  the  corresponding  margins  of  the  lateral 
segments,  transform  the  condition  into  a  double,  incomplete  hare- 
lip and  later  do  a  second  operation  to  correct  this.  If  the  nose  is 
flattened  and  the  alse  spread  out,  one  should  try  to  correct  this 
deformity  at  the  same  time  by  separating  the  lateral  segments  of 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC. 


105 


the  lips  and  the  sides  of  the  nose  from  their  deep  attachments. 
Instead  of  the  Malgaigne,  a  double  Hagedorn  may  be  done  for  this 
condition. 

Operation  for  Double  Harelip  with  Prominent  Advanced  Inter- 
maxillary Bone. — This  may  be  remedied  by  resecting  the  bony  part 
of  the  prominent  intermaxillary  portion,  leaving  the  soft  parts  to 
assist  in  making  the  lip.  The  middle  segment  may  be  placed  very  far 
forward  upon  or  near  the  point  of  the  nose,  in  which  case  the  cuta- 


'''■f/r/r/,/7//>?r'' 


Fig. 
gaigne 
Double 


53.  —  Double  Mal- 
Operation  for  a 
Complete  Harelip. 
Paring  of  edges  of  defects 
and  formation  of  flaps. 


''rf/r/wrffff 

Fig.     54.  —  Flaps    Turned 
down     ready     for     Suture. 


'''''//■/Orrrs/i'/r'*' 

Fig.    55.— Result   After   Su- 
ture. 


A       « 


^rrrrrrrr''' 

''Trrrr/rrr' 

Parts  Ready  for 

Fig. 

58. 

-Result   After    Su 

Suture. 

ture. 

Fig.   56.— Hagedorn   Oper-      Fig.  57. 
ation   for   Complete   Double 
Harelip.      Paring    and    for- 
mation of  flaps. 


neous  part  of  the  septum  of  the  nose  is  absent  (see  Fig.  31).  Under 
these  circumstances  the  soft  parts  of  the  middle  segment  of  the  lip 
must  be  used  to  make  the  tegumentary  part  of  the  nasal  septum,  and 
then  the  whole  lip  must  be  formed  from  the  two  lateral  segments 
without  the  assistance  of  the  middle  portion.  It  may  be  necessary 
to  liberate  the  flaps  by  separating  them  from  the  alveolar  process  of 
the  superior  maxillary  or,  in  addition  to  this,  by  making  an  incision, 
upon  either  side,  around  the  ala  of  the  nose  (Wellenschnitt  of  Dieffen- 
bach). 


106  HEAD  AND  FACE. 

An  attempt  may  be  made  to  gradually  force  the  intermaxillary 
segment  into  place  by  long-continued  pressure.  If  this  method  is 
to  be  tried,  the  double  cleft  is  closed  after  having  first  liberated  the 
side  flaps  by  an  incision,  on  either  side,  around  the  wing  of  the  nose 
(Dieffenbach's  Wellenschnitt),  and  then  an  elastic  band  is  applied  which 
■exerts  pressure,  continuously,  upon  the  middle  segment.  This  band- 
age must  we  worn  for  a  long  time. 

Immediate  forcible  replacement  of  the  intermaxillary  portion 
may  be  done.  It  is  seized  with  the  forceps  and  broken  away  from  the 
vomer,  or  the  line  of  fracture  may  extend  upward  and  backward 
through  the  vomer  proper.  The  segment  is  then  forced  back  into 
ju'oper  position  and  the  edges  of  the  flaps  freshened  and  sutured. 

Blandin  recommends  the  resection  of  a  triangular-shaped  por- 
tion from  the  nasal  septum  posterior  to  the  intermaxillary  segment. 
The  base  of  the  triangular  piece  of  bone  which  is  thus  resected 
corresponds  in  width  to  the  space  that  intervenes  between  the  mid- 
dle segment  and  the  intermaxillary  notch,  its  apex  running  upward 
into  the  septum  of  the  nose.  In  young  children  this  resection  may 
be  made  with  a  pair  of  ordinary  strong  scissors,  but  in  children 
over  ten  years  of  age  it  will  be  necessary  to  use  the  bone  scissors. 
The  apex  of  the  resected  triangular  piece  should  be  directed  upward 
and  forward,  toward  the  bridge  of  the  nose,  in  order  to  avoid  the 
anterior  palatine  vessels.  The  intermaxillary  segment  may  then 
be  readily  forced  back  into  proper  position  and  the  cleft  closed.  If 
the  anterior  naso-palatine  artery  is  cut  in  removing  the  triangular 
piece  of  bone,  the  hemorrhage  will  be  severe. 

Bardeleben  has  modified  the  above  procedure  in  that  he  first 
separates  the  periosteum,  upon  either  side  of  the  septum,  behind  the 
middle  segment,  and  then,  with  the  ordinary  strong,  straight  scissors, 
simply  cuts  through  the  septum  without  attempting  to  resect  a  tri- 
angular piece.  The  middle  segment  is  then  pushed  back  into  place, 
the  edges  of  the  divided  septum  sliding  past  and  overlapping. 

As  a  rule,  the  attempt  to  replace  the  middle  segment  should 
be  made  during  the  first,  second,  or  third  year  of  the  patient's  life, 
because  later  the  segment  becomes  too  large  and  the  corresponding 
intermaxillary  space  too  small. 

Many  surgeons  make  it  a  rule  to  excise  the  intermaxillary  bone 
entirely,  and  indeed  it  is  very  questionable  if  anything  is  gained  by 
leaving  or  replacing  a  deformed,  misplaced  middle  portion.  If  it  is  re- 
moved, the  four  incisor  teeth  are  lost,  but  a  plate  can  be  fitted  to  sub- 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC.  107 

■stitute  for  these.  If  the  intermaxillary  bone  is  allowed  to  remain  and 
is  replaced,  it  is  very  likely  to  remain  rudimentary  and  wabbly,  and  the 
corresponding  teeth  are  apt  to  be  crooked  and  imperfect.  If  a  con- 
siderable part  of  the  septum  of  the  nose  has  been  removed,  in  order  to 
place  the  intermaxillary  portion  in  its  normal  position,  the  point  of  the 
nose  will  be  drawn  down  so  close  to  the  front  of  the  face  as  to  give  it  a 
peculiar  flattened,  "bird-like"  appearance. 

Operation  for  Cleft  Palate. — The  cleft  may  be  limited  to  the 
soft  or  hard  palate  or  may  extend  through  both. 

The  operation  upon  the  soft  palate  is  called  staphylorrhaphy; 
that  upon  the  hard  palate,  uranoplasty.  At  times  cleft  palate  is 
combined  with  harelip.  This  latter  condition  may  be  remedied  dur- 
ing the  first  few  months  of  life,  leaving  the  cleft  in  the  palate  until 
later:  seventh  to  eighth  year.  Julius  Wolff  operates  upon  cleft 
palate  earlier,  during  the  second  or  third  year,  and  this  seems  ad- 
visable. The  operation  for  closure  of  a  complete  cleft  may  be  done 
in  two  sittings:  closure  of  the  hard  palate  first  and  the  soft  palate 
subsequently  at  a  second  sitting.  As  a  rule,  however,  it  is  preferable 
to  close  the  entire  cleft  at  one  sitting. 

The  operation  is  probably  best  done  with  the  head  in  the  Eose 
position,  the  patient  lying  upon  the  back,  with  the  head  hanging 
over  the  end  of  the  table,  and  under  complete  anaesthesia  (chloro- 
form). Some  operators  advise  a  preliminary  tracheotomy  with  the 
introduction  of  a  tampon  cannula,  or  an  ordinary  tracheotomy  tube 
may  be  introduced,  in  this  latter  case,  packing  the  pharynx,  in  addi- 
tion, with  a  pad  of  gauze.  Blood  is  thus  prevented  from  entering 
the  larynx,  and  the  anaesthetic  is  administered  through  the  trache- 
otomy tube.  Even  when  these  measures  are  resorted  to,  the  Rose 
position  is  still  preferable.  The  mouth,  teeth,  and  nasal  passages 
should  be  thoroughly  cleansed  and  disinfected,  and  during  the  op- 
eration the  mouth  and  nose  may  be  frequently  irrigated  with  a  hot, 
saline  solution,  which  cleanses  the  parts  and  checks  hemorrhage.  The 
corners  of  the  mouth  are  retracted  with  curved  retractors  held  by 
an  elastic  band  fastened  around  the  patient's  neck.  The  jaws  are 
held  apart  with  a  Smith  or  Whitehead  gag,  which  not  only  holds 
the  jaws  open,  but  at  the  same  time  depresses  the  tongue.  If  this 
gag  is  used,  the  retractors  for  the  side  of  the  mouth  may  be  dis- 
pensed with.  Bleeding  is  controlled  by  pressure  with  hot  pads  on 
long  sponge  holders,  and  one  should,  at  short  intervals,  interrupt 
the  operation  for  this  purpose;  usually  the  hemorrhage  is  simply  an 


108  HEAD  AXD  FACE. 

oozing  from  the  cut  edges.  By  carefully  minimizing  the  loss  of  blood 
we  are  enabled,  with  safety,  to  operate  upon  quite  young  children: 
less  than  two  years  of  age  (Julius  Wolff). 

Staphylorrhaphy. — Closure  of  a  split  in  the  soft  palate.  The 
first  step  of  the  operation  consists  in  freshening  the  edges  of  the  cleft. 
The  free  extremity  of  one  side  of  the  split  uvula  is  seized  with  a  long 
mouse-tooth  forceps,  and,  while  the  uvula  is  thus  held  taut,  it  is 
transfixed,  near  its  tip,  which  is  steadied  in  the  grasp  of  the  forceps, 
with  a  narrow-bladed,  sharp-pointed,  double-edged  knife,  and  with  a 
sawing  motion  a  thin  strip  is  cut  away  from  its  margin;  the  edge 
is  pared  along  the  entire  extent  of  the  split  toward  the  posterior 


Fig.  59.— Whitehead  Gag  and  Tongue  Depressor  in  Place.     For  operations 
upon  the  hard  and  soft  palate. 


border  of  the  hard  palate.  The  opposite  edge  is  then  freshened 
in  a  like  manner  and  the  strips  finally  cut  away  from  the  tip  of  the 
uvula.  Care  should  be  taken  to  freshen  the  angle  of  the  split.  The 
strips  should  be  so  cut  that  the  freshened  margins  present  a  beveled 
edge,  more  tissue  being  taken  away  from  the  buccal  than  from  the 
nasal  aspect  of  the  soft  palate,  as  this  gives  us  broader  surfaces  for 
suture.  The  freshening  of  the  margin  of  the  split  may  be  done  with 
long,  narrow-bladed  scissors  instead  of  with  the  knife.  After  the 
edges  have  been  freshened,  one  should,  with  sharp  tenacula,  attempt 
to  appose  the  raw  edges  in  order  to  estimate  what  degree  of  tension, 
if  any,  exists.  It  is  absolutely  necessary  that  there  be  no  tension 
whatever.    In  order  to  overcome  tension  of  the  soft  palate  a  liberat- 


OPERATIONS  FOR  HARELIP,  CLEFT  PALATE,  ETC.  109 

ing  incision  may  be  made  upon  either  side.  These  incisions  are  made 
with  a  narrow-bladed,  double-edged  knife,  which  is  introduced  just  to 
the  inner  side  of  the  hamular  process.  This  process,  which  is  located 
behind  and  internal  to  the  last  molar  tooth,  is  very  readily  felt. 
These  incisions  pass  through  the  entire  thickness  of  soft  palate,  from 
behind  forward,  and  divide  the  tendons  of  the  levator  and  tensor 
palati  as  they  turn  around  the  hamular  process  to  spread  out  into 
the  soft  palate.  One  may  wait  with  these  incisions  until  after  the 
soft  palate  has  been  sutured,  since  they  may  not  be  necessary,  espe- 
cially if  care  has  been  taken  to  thoroughly  detach  the  soft  palate 
from  the  posterior  border  of  the  hard  palate  and  also  from  the 
adjoining  portion  of  the  pterygoid  process,  which  corresponds  to  the 
most  external  portion  of  the  posterior  border  of  the  hard  palate. 
If  this  separation  is  thorough,  the  two  halves  of  the  soft  palate  may 
be  readily  approximated  without  tension,  and  the  liberating  incisions 
can  then  be  dispensed  with  (Julius  Wolff).  Even  when  the  cleft  is 
limited  to  the  soft  palate,  one  may  with  advantage  raise  a  muco- 
periosteal  flap,  as  when  closing  clefts  of  the  hard  palate;  so  that, 
working  underneath  this  flap,  close  to  the  surface  of  the  bone,  the 
soft  palate  may  be  completely  separated  from  the  posterior  border 
of  the  hard  palate.  This  may  be  done  with  a  periosteum  elevator 
bent  upon  itself  near  the  end  to  almost  a  right  angle. 

To  unite  the  freshened  edges  of  the  soft  palate  a  small,  short, 
surgeon's  needle  with  a  moderate  curve  or  a  short,  straight  needle 
may  be  used.  The  needle  is  carried  in  a  long  needle  holder,  and  as 
it  pierces  the  tissues  its  end  may  be  seized  with  an  artery  forceps 
for  the  purpose  of  withdrawing  it.  A  combination  needle  and  holder 
in  one  piece  is  preferred  by  some  surgeons. 

The  stitches,  which  may  be  of  silk,  silk-worm  gut,  or  silver  wire, 
are  introduced  from  before  backward,  and  are  not  tied  until  they 
are  all  placed.  Instead  of  tying  the  sutures  they  may  be  fixed  with 
perforated  shot.  To  prevent  the  suture  ends  becoming  confused 
one  may  confine  them  temporarily,  until  ready  to  tie  them,  in  in- 
cisions cut  in  a  piece  of  cardboard.  From  four  to  five  sutures  are 
required,  and  they  should  be  placed  about  one-fourth  inch  apart. 
The  edges  of  the  soft  palate  should  be  accurately  apposed  without 
tension  and  free  from  hemorrhage. 

Uranoplasty. — Closure  of  clefts  of  the  hard  palate.  The  op- 
eration of  Langenbeck  as  described  by  him  in  1862.  This  condition 
is  usually  associated  with  cleft  of  the  soft  palate,  in  which  case  both 


110  HEAD  AND  FACE. 

should  be  closed  at  the  same  time.  The  tip  of  one  side  of  the  uvula 
is  seized  with  a  long,  mouse-tooth  forceps  and  transfixed  as  described 
above.  The  paring  process  is  carried  forward  as  far  as  the  poste- 
rior border  of  the  hard  palate  and  then  continued  along  the  margin 
of  the  cleft  in  the  hard  palate,  close  to  its  edge,  cutting  through  the 
muco-periosteal  covering  down  to  the  surface  of  the  bone,  as  far  as 
the  anterior  limit  of  the  cleft.  Upon  the  other  side,  beginning,, 
again,  behind,  near  the  tip  of  the  soft  palate,  the  margin  of  the 
cleft  in  the  soft  palate  and  in  the  hard  palate  is  freshened  in  a 
similar  manner.  During  this  step  of  the  operation  one  should  pause- 
occasionally  for  a  few  minutes  and  apply  steady,  firm  pressure  with 
a  hot  pad  in  order  to  control  the  bleeding. 

The  next  step  of  the  operation  is  the  raising  of  a  muco-periosteal 
flap  from  the  surface  of  the  hard  palate  upon  either  side  of  the 
cleft.  An  incision,  corresponding  to  the  length  of  the  cleft,  is  made 
upon  the  surface  of  the  hard  palate  and  close  along  the  inner  margin 
of  the  alveolar  process.  This  incision  usually  extends  from  a  point 
anteriorly,  behind  the  incisor  teeth,  to  a  point  posteriorly,  beyond 
the  last  molar  tooth.  In  making  this  incision  we  should  remember 
the  point  where  the  posterior  palatine  artery  emerges  from  the  canal 
in  the  back  part  of  the  palate,  and  place  the  incision  fairly  close  to 
the  alveolar  process  so  that  this  vessel  may  be  left  in  the  flap  to 
nourish  it  and  also  in  order  that  we  may  avoid  the  hemorrhage  that 
would  follow  its  division.  Many  surgeons  claim  that  it  is  a  matter  of 
indifference  whether  this  vessel  is  cut  or  not,  as  the  flap  is  nourished 
just  the  same  in  either  case  and  that  the  resulting  hemorrhage  is  read- 
ily controlled  by  pressure;  nevertheless  one  should  try  to  avoid  divid- 
ing it.  Into  this  incision  a  sharp  periosteum  elevator  is  introduced, — 
it  may  be  narrow  and  rather  bent  near  the  end, — and  with  this  the 
muco-periosteal  layer  is  lifted  away  from  the  surface  of  the  bone  and 
thus  made  freely  movable  so  that  it  can  be  brought  over  to  meet  the 
edges  of  the  flap  on  the  opposite  side.  Care  should  be  exercised  to 
separate  thoroughly  the  soft  palate  from  the  whole  posterior  border  of 
the  hard  palate.  This  is  accomplished  by  working  close  to  the  surface 
of  the  bone  with  a  periosteum  elevator  bent  upon  itself.  If  this 
detachment  of  the  soft  palate  is  thorough,  it  will,  in  nearly  all  in- 
stances, do  away  with  the  necessity  for  liberating  incisions,  etc. 

The  apposed  edges  of  the  cleft  are  now  sutured  together,  com- 
mencing in  front,  behind  the  incisor  teeth,  and  working  backward, 
completing  the  operation  by  uniting  the  edges  of  the  soft  palate.    As 


OPERATIONS  UPON  THE  LIPS. 


Ill 


already  mentioned,  the  sutures  are  not  tied  until  after  they  have 
all  been  placed.  The  raw  space  left  on  either  side  of  the  hard 
palate  after  raising  the  muco-periosteal  flaps  is  packed. 

Ordinarily  the  sutures  may  he  removed  after  six  days.  The 
mouth  and  nose  should  be  irrigated  and  washed  out  frequently  both 
during  and  subsequent  to  the  operation.  If  a  preliminary  trache- 
otomy has  been  performed  the  mouth  may  be  packed,  the  patient 
breathing  freely  through  the  tracheotomy  tube.  The  original  defect 
of  the  hard  palate  is  closed  ultimately  by  bone  produced  from  the- 
periosteal  surface  of  the  flaps. 


Fig.  60. — Repair  of  Cleft  Palate.  Muco-periosteal  flaps  raised  and  edges 
of  cleft  in  hard  and  soft  palate  pared.  Sutures  all  introduced  and  ready  for 
tying. 


OPERATIONS  UPON  THE  LIPS. 

Excision  of  the  Whole  Lower  Lip. — This  operation  is  done  for 
malignant  disease.  At  times  the  angle  of  the  mouth  is  involved 
and  the  upper  lip  is  also  encroached  upon,  so  that  it  becomes  neces- 
sary, in  addition  to  excising  the  lower  lip,  to  excise  a  triangular 
portion  of  the  upper  lip.  The  cutting  is  done  with  a  scissors,  and 
during  the  operation  the  bleeding  is  controlled  by  compression  with 
the  fingers.  If  the  jaw-bone  is  involved  in  the  disease  one  may  resect 
the  diseased  portion  with  the  chisel  or  saw,  but  should  leave,  if  pos- 
sible, a  bridge  of  bone  sufficient  to  preserve  the  continuity  of  the 
jaw. 


112 


HEAD  AKD  FACE. 


Restoration  of  the  Lower  Lip  After  Excision  of  a  Wedge-shaped 
Portion. — After  the  whole  lower  lip  has  been  removed,  the  triangular- 
shaped  defect  that  remains  may,  in  many  cases,  be  remedied  by  sim- 
ply drawing  the  edges  of  the  wound  together.  The  edges  of  the 
wound  may  be  united  with  several  sutures  of  rather  heavier  silk 
which  go  through  the  entire  thickness  of  the  lip  down  to,  but  not 
including,  the  mucous  membrane,  and  these  may  be  placed  so  as 
to  control  the  hemorrhage  at  the  same  time.  There  are  then  applied 
additional  sutures  of  finer  silk  that  bring  the  edges  of  the  wound 
accurately  together.  As  a  result,  we  have  a  small,  rounded,  puck- 
ered opening,  representing  the  mouth,  which  is  formed  entirely  from 


Fig.  61.— Excision  of  Entire  Lower 
Lip,  with  Resulting  Triangular  De- 
fect. 


Fig.    62.— Triangular    Defect    in    Lower 
Lip  Closed  by  Suture. 


the  upper  lip,  but  this  regains  an  appearance  very  much  like  normal, 
after  six  to  eight  months. 

Formation  of  the  Lower  Lip  After  Complete  Excision.  Dieffen- 
bach-Jaesche  Method. — To  remedy  a  triangular  defect  in  the  lower 
lip.  In  estimating  the  area  of  the  flaps  required  one  should  allow 
one-third  for  shrinkage. 

From  each  corner  of  the  mouth  an  incision  is  carried  outward 
and  somewhat  upward  into  the  cheek  for  a  sufficient  distance  to 
close  the  defect  in  the  lip,  allowing  one-third  for  shrinkage.  From 
the  end  of  each  of  these  incisions  a  second  curved  incision  is  then 
carried  downward  and  inward  toward  the  chin  so  as  to  terminate 
near  the  lower  border  of  the  jaw  and  under  the  angle  of  the  mouth. 


OPERATIONS  UPON  THE  LIPS.  113 

Stenson's  duct  should  be  avoided  in  making  these  flaps.  This  second 
incision,  being  curved,  makes  the  flaps  more  movable.  The  mucous 
membrane,  corresponding  to  that  part  of  the  incision  that  reaches 
outward  from  the  corner  of  the  mouth,  should  be  cut  upon  a  higher 
level  than  the  skin  in  order  thus  to  obtain  a  mucous  membrane  flap 
which  may  be  sutured  to  the  edge  of  the  skin  to  form  the  free  border 
of  the  new  lower  lip.  For  the  rest  of  its  extent  the  incision  goes 
through  the  skin  and  mucous  membrane  upon  the  same  level.  The 
two  flaps  are  now  separated  from  the  lower  jaw,  avoiding,  as  far  as 
possible,  cutting  the  fold  of  mucous  membrane  that  is  reflected  from 
the  inner  surface  of  the  lips  to  the  gums.  If  the  flaps  are  not  suffi- 
ciently movable  to  bring  them  together,  the  incisions  may  be  pro- 


Fig.  63. — Dieffenbach-Jaesche  Operation  for  Restoring  Lower  Lip.  Dotted 
lines  represent  the  edges  of  the  mucous  membrane,  which  is  cut  long  in  order 
to  cover  over  the  free  margin  of  the  new  lip.  The  edges  of  the  flaps  are 
drawn  together  and  the  mucous  membrane,  which  was  cut  long,  is  sewed 
over  the  free  edge  of  the  new  lip.  The  defect  upon  each  side  caused  by  the 
sliding  of  the  flaps  is  closed  by  suture. 

longed  downward  beyond  the  lower  border  of  the  jaw  into  the  neck 
and  the  flaps  loosened  still  farther  from  the  lower  jaw.  The  edges 
of  the  flaps  are  then  united  with  interrupted  silk  sutures  which  in- 
clude the  whole  thickness  of  the  lip  down  to,  but  not  including,  the 
mucous  membrane.  A  second  set  of  intermediate  silk  sutures  brings 
the  edges  of  the  skin  and  mucous  membrane  into  accurate  apposi- 
tion. Corresponding  to  the  free  border  of  the  new  lip,  the  edges 
of  the  mucous  membrane  flaps,  which  were  intentionally  cut  long, 
are  sutured  to  the  skin.  Finally  the  semilunar  defects  upon  either 
side  are  closed  with  sutures.  In  the  male  the  scar  is  hidden  by  the 
beard. 

Beuns  Method. — For  a  quadrangular  defect  of  the  lower  lip. 
A  square  cornered  flap  is  taken  from  either  side  of  the  face,  includ- 


114 


HEAD  AND  FACE. 


ing  the  whole  thickness  of  the  cheek,  and  these  are  turned  down 
into  the  defect  through  an  angle  of  ninety  degrees.  These  flaps 
have  a  good  blood-supply.     Avoid  Stenson's  duct.     The  apposed 


Fig.  64.— Bruns  Method  of  Restoring 
the  Lower  Lip.  Dotted  lines  indicate 
that  the  mucous  membrane  is  cut 
longer  than  the  skin  in  order  to  pro- 
vide a  mucous  membrane  border  to  the 
new  lip. 


Pig.  65.— Flaps  Turned  down  and 
Joined  to  Form  New  Lip.  Mucous 
membrane  is  sutured  over  the  free 
margin  of  the  new  lip.  The  defect 
upon  each  side  of  the  cheek  is  closed 
by  suture. 


edges  of  the  flaps  are  united  and  the  mucous  membrane  sutured  to 
the  edge  of  the  skin  to  form  the  free  margin  of  the  new  lip.  The 
lateral  defect  on  either  side  is  then  closed.  The  scars  that  result  are 
upon  the  cheek. 


Fig.  66.— Langenbeck  Method  of  Re- 
storing the  Lower  Lip.  An  oval  nap  is 
taken  from  the  region  of  the  chin. 


Fig.  67.— Oval  Flap  is  Raised  and  Su- 
tured into  Place  and  the  Defect  thus 
Closed. 


Langenbeck's  Method. — Formation  of  the  lower  lip  for  oval 
defect.  A  long,  rounded  flap  is  taken  from  the  region  of  the  chin 
with  its  base  directed  upward  and  outward.     Between  the  upper 


OPERATIONS  UPON  THE  LIPS. 


115 


border  of  the  flap  which  is  thus  marked  out  and  the  lower  margin 
of  the  defect  there  is  a  triangular  tongue  of  tissue.  This  tongue  of 
tissue  is  partly  loosened  from  its  attachment  to  the  underlying  tis- 
sues. The  long  flap  is  raised  from  the  underlying  parts  and  shoved 
upward,  filling  in  the  defect  in  the  lip,  and  the  triangular  tongue 
of  tissue  is  brought  under  it.  These  flaps  are  fixed  in  their  new 
position  with  sutures.  The  whole  defect  may  be  closed  over  if  the 
flaps  are  sufficiently  detached.  The  great  disadvantage  of  this 
method  is  that  the  new  lip,  upon  its  free  edge  and  posterior  surface, 
is  not  covered  by  mucous  membrane,  and  shrinks  and  contracts  as 
it  cicatrizes. 


Pig.  6S.— Estlander's  Method  of  Re- 
storing the  Lower  Lip  After  Partial 
Excision.  A  triangular  flap  is  taken 
from  the  upper  lip  and  cheek. 


Fig.  69.  —  The  Triangular  Flap  is 
Turned  down  and  Sutured  in  Place, 
thus  Closing  the  Defect. 


Estlandek's  Method. — As  large  a  defect  as  that  left  after 
excision  of  three-fourths  of  the  lower  lip  may  be  covered  by  this 
method.  An  incision  is  made  reaching  from  the  corner  of  the  mouth 
upward,  through  the  whole  thickness  of  the  cheek,  to  the  level  of  the 
infra-orbital  foramen  and  then  downward,  past  the  wing  of  the  nose, 
toward  the  philtrum,  to  a  point  close  to  the  carmine  border  of  the 
upper  lip.  If  the  coronary  branch  of  the  facial  artery  is  not  divided, 
the  flap  will  be  well  nourished.  The  flap  is  then  turned  down  into 
the  defect  in  the  lower  lip  through  an  angle  of  one  hundred  and 
seventy  degrees.  One  may  feel  the  pulsating  coronary  artery  before 
cutting  the  flap  and  should  positively  avoid  severing  it. 

The  resulting  deformity  is  bad,  the  mouth  one-sided,  the  corner 
of  the  mouth  corresponding  to  the  philtrum.  In  order  to  correct  this 
feature  one  might,  subsequently,  do  another  operation,  extending  the 


116 


HEAD  AND  FACE. 


corner  of  the  mouth  outward,  but  it  would  be  necessary  to  wait  at  least 
six  weeks,  in  order  to  insure  a  good  blood-supply,  before  undertaking 
this  second  operation;  otherwise  there  would  be  danger  of  gangrene. 
Without  doubt  this  deformity  will,  in  time,  correct  itself  to  a  consider- 
able degree,  so  that  the  secondary  operation  may  not  be  necessary. 


WD 


Fig.  70. — Dieffenbach  Wellenschnitt  for 
Restoration  of  the  Upper  Lip.  An  in- 
cision (WD)  is  carried  around  each  side 
of  the  nose,  extending  through  the 
cheek. 


Fig.  71.— The  Flaps  are  Liberated 
from  the  Upper  Jaw-bone  and  are 
Drawn  Down  into  Place  and  Sutured. 
The  raw  space  upon  either  side  of  the 
nose  is  closed  with  suture. 


Restoration  of  the  Upper  Lip. — Eestoration  of  the  upper  lip  is 
not  often  required,  as  this  part  is  but  rarely  the  seat  of  disease  that 
calls  for  its  excision. 


Fig.  72.— Bruns  Method  of  Restoring 
Upper  Lip.  A  square  flap  taken  from 
either  cheek. 


Fig.  73. — Flaps  are  Turned  down  into 
Place  and  Sutured.  Defect  in  either 
cheek  is  closed  with   sutures. 


Estlander's  Method  may  be  used  to  close  a  wedge-shaped 
defect  in  the  upper  lip,  the  flap  being  taken  from  the  lower  lip. 

Dieffenbach's  Wellenschnitt. — A  curved  incision  is  made 
through  the  whole  thickness  of  the  cheek  around  the  corner  of  the 


OPERATIONS  UPON  THE  LIPS.  117 

nose.  The  flaps  which  are  thus  marked  out  are  separated  from  the 
maxillae  and  then  drawn  toward  the  middle  line  and  turned  down, 
so  that  the  raw  edges  of  the  original  defect  become  the  free  border 
of  the  new  lip.  The  two  flaps  are  then  united  and  the  edges  of  the 
mucous  membrane  and  skin  sutured  together  along  the  free  margin 
of  the  new  lip.  The  mucous  membrane  corresponding  to  this  margin 
may  be  cut  a  little  longer  than  the  skin,  in  order  to  facilitate  the 
union  of  these  edges.  After  uniting  the  flaps  in  the  middle  line  the 
edges  of  the  defect  around  the  side  of  the  nose  may  be  brought 
together  with  sutures. 

Small,  wedge-shaped  defects  may  be  closed  by  simple  suture, 
if  necessary,  combining  this  with  detachment  of  the  cheek  by  Dief- 
fenbach's  Wellenschnitt. 

Beuns  Method  may  also  be  used  to  restore  the  upper  lip  after 
its  complete  excision. 


PART  III. 

NECK   AND   TONGUE. 


SURGICAL  ANATOMY  OF  THE  NECK. 

The  neck  is  the  constricted  part  of  the  body  that  joins  the  head 
to  the  trunk.  The  spinal  column  passes  through  the  posterior  part 
of  the  neck,  inclosing  within  its  canal  the  spinal  cord.  The  anterior 
part  of  the  neck  is  made  up  of  important  organs  and  of  channels 
that  pass  between  the  head  and  the  trunk. 

The  Deep  Cervical  Fascia. — This  is  an  aponeurotic  layer  that 
serves  to  bind  the  structures  that  comprise  the  neck,  into  a  com- 
pact, cylindrical  mass.  This  fascia  offers  a  strong  barrier  to  the 
extension  of  superficial  suppurative  processes  into  the  deeper  parts 
of  the  neck,  and  at  the  same  time  hinders,  to  a  considerable  degree, 
the  sjjontaneous  evacuation,  externally,  of  pus  which  is  located  deep 
in  the  neck. 

Anteriorly,  between  the  edges  of  the  sterno-mastoid  muscle,  the 
deep  cervical  fascia  covers  the  depressor  muscles  of  the  hyoid  bone — 
the  sterno-hyoid,  sterno-thyroid,  and  omo-hyoid.  Upon  the  side  of 
the  neck  it  is  found  beneath  the  sterno-mastoid,  and  may  be  traced 
from  the  posterior  border  of  this  muscle  backward  across  the  poste- 
rior triangle  of  the  neck  and  beneath  the  trapezius  muscle,  where 
it  serves  to  bind  the  long  muscles  of  the  neck  to  the  vertebral 
column. 

Above,  the  deep  cervical  fascia  is  attached  to  the  lower  border 
of  the  jaw  and  to  the  back  of  the  skull,  and,  below,  to  the  upper 
border  of  the  sternum,  the  clavicle,  the  spine  of  the  scapula,  and 
the  spinous  process  of  the  seventh  cervical  vertebra:  vertebra  prom- 
inens.  In  the  middle  line  of  the  neck,  behind,  the  deep  cervical 
fascia  is  blended  with  the  ligamentum  nucha?,  which  is  prolonged 
deep  into  the  neck  to  be  attached  to  the  tips  of  the  spinous  processes 
of  the  cervical  vertebras.  The  deep  cervical  fascia  is  firmly  attached 
to  the  body  and  horns  of  the  hyoid  bone. 

Anteriorly,  between  the  edges  of  the  sterno-mastoid  muscles, 
the  deep  cervical  fascia  covers  the  depressor  muscles  of  the  hyoid 
bone,  and  consists  of  two  layers,  the  anterior  of  which  is  attached 
(118) 


Fig.  74. — Section  through  the  Neck,  Level  of  Sixth  Cervical  Vertebra,  to  Show  Arrangement 
of  the  Deep  Cervical  Fascia  (Indicated  in  Red) .  BP,  trunks  of  brachial  plexus  ;  C,  complexus 
muscle  ;  EJ,  external  jugular  vein  ;  ES,  oesophagus  ;  LA,  levator  anguli  scapula?  muscle  ;  OH, 
omo-hyoid  muscle:  P,  platysma  muscle;  PV,  pravisceral  space;  RV,  retrovisceral  space;  S, 
S',  splenius  capitis  et  colli  muscle  ;  SA,  scalenus  amicus  muscle  ;  SC,  semispinalis  colli  muscle; 
SH,  sterno-hyoid  muscle  ;  SM,  scalenus  medius  muscle ;  SS,  suprasternal  space ;  ST,  sterno- 
thyroid muscle  ;  ST.M.,  sterno-mastoid  muscle  ;  SY,  sympathetic  nerve  ;  TP,  trapezius  muscle  ; 
TR,  trachea ;  TY,  thyroid  gland;  V,  vertebral  artery  and  vein;  VAN,  internal  jugular  vein, 
carotid  artery,  and  pneumogastric  nerve  inclosed  in  a  mass  of  loose  connective  tissue. 


SURGICAL  ANATOMY  OF  THE  NECK.  119 

to  the  anterior  and  the  posterior  to  the  posterior  margin  of  the 
upper  border  of  the  sternum.  Between  the  two  layers  there  is  a 
space  known 'as  the  suprasternal  space,  which  contains  some  fat, 
lymphatic  tissue,  and  a  venous  branch,  the  anterior  jugular,  that 
enters  the  external  jugular  beneath  the  attachment  of  the  sterno- 
mastoid. 

The  suprasternal  space  extends  upward  almost  as  far  as  the 
hyoid  bone  and  laterally  as  far  as  the  anterior  edge  of  the  sterno- 
mastoid  muscle. 

A  suppurative  process  in  this  space  is  pretty  effectively  shut  off 
from  the  deep  parts  of  the  neck  by  the  posterior  layer  of  the  deep 
cervical  fascia. 

In  the  front  part  of  the  neck,  below  the  level  of  the  hyoid  bone, 
the  pharynx  and  oesophagus  and  the  larynx  and  trachea  are  bound 
together  in  a  single  bundle  by  a  layer  of  fascia  that  completely  en- 
velops them;  the  thyroid  gland  is  also  included  within  this  sheath 
of  fascia  and  is  fixed  by  it  to  the  trachea.  Another  layer  of  fascia 
forms  a  sheath  for  the  muscles  that  are  contiguous  to  the  vertebral 
column:  anteriorly,  the  recti  and  longus  colli;  laterally,  the  scaleni, 
cords  of  the  brachial  plexus,  and  the  levator  anguli  scapulae;  poste- 
riorly, the  splenius,  complexus,  etc. 

Above  the  hyoid  bone  the  deep  cervical  fascia  reaches  from  the 
body  of  the  jaw-bone  to  the  hyoid  bone.  The  submaxillary  gland, 
surrounded  by  a  mass  of  loose  connective  tissue,  is  lodged  in  the 
submaxillary  triangle,  beneath  the  deep  cervical  fascia. 

Connective-Tissue  Spaces  Beneath  the  Deep  Cervical 
Fascia.  Prcevisceral  Space. — This  space  corresponds  to  a  mass  of 
loose  connective  tissue  that  is  situated  in  front  of  the  trachea  and 
thyroid  gland  and  beneath  the  deep  cervical  fascia  and  depressor 
muscles  of  the  hyoid  bone. 

If  an  opening  is  made  in  the  deep  fascia  and  a  probe  introduced 
into  this  space,  it  may  be  readily  forced  down  into  the  mediastinum, 
and  a  collection  of  pus  in  this  space  may  readily  gravitate  along  the 
same  route  into  the  mediastinum  with  fatal  results. 

Retrovisceral  Space. — This  is  the  recess  between  the  pharynx 
and  oesophagus  in  front  and  the  vertebral  column  behind;  it  reaches 
from  the  base  of  the  skull  down  into  the  chest.  Pus  in  this  space 
may  readily  find  its  way  down  along  this  path  into  the  chest. 

Vascular  Space. — Upon  either  side  of  the  pharynx  and  oesoph- 
agus and  the  larynx  and  trachea  the  carotid  artery  and  its  adjoining 


120  NECK  AND  TONGUE. 

structures  are  found.  These  structures,  beside  the  carotid  artery, 
consist  of  the  internal  jugular  vein  and  pneumogastric  nerve,  sym- 
pathetic nerve,  and  loop  formed  by  the  descendens  and  communicans 
noni.  These  structures  are  not  provided  with  a  distinct  sheath,  but 
are  lodged  in  a  mass  of  loose  connective  tissue,  which  may  be  traced 
all  the  way  down  into  the  thoracic  cavity. 

Suppuration  may  spread  along  the  course  of  these  structures, — 
for  example,  the  internal  jugular  vein, — and  thus  invade  the  chest 
cavity. 

The  Back  of  the  Neck. — This  region  of  the  neck  corresponds  to 
the  cervical  portion  of  the  trapezius  muscle.  It  is  limited  above  by 
the  occipital  protuberance  and  superior  curved  line  of  the  occipital 
bone,  below  by  the  vertebra  prominens,  and  upon  the  sides  by  the 
edges  of  the  trapezius  muscle. 

The  skin  of  this  region  is  intimately  united  with  the  subcuta- 
neous connective  tissue,  which  is  very  dense  and  is  marked  by  hair- 
follicles  and  sebaceous  glands.  Inflammatory  processes  which  attack 
the  structures  of  the  skin  in  this  region  show  but  little  tendency 
to  spread  and  are  excessively  painful  (carbuncles). 

This  region  presents  two  longitudinal,  rounded  swellings — one 
on  either  side  of  the  middle  line — which  correspond  to  the  trapezius 
muscle.  Between  these,  in  the  middle  line,  is  a  depression  marked 
by  the  spinous  processes  of  the  cervical  vertebras.  The  spinous 
processes  of  the  cervical  vertebras  are  short  and  not  distinctly  felt, 
except  the  lower  ones;  that  of  the  seventh,  the  vertebra  prominens, 
is  especially  prominent.  They  are  joined  together  by  a  dense,  liga- 
mentous band, — the  ligamentum  nuchas, — which  is  continued  upward 
as  far  as  the  external  occipital  protuberance.  The  cervical  portion 
of  the  vertebral  canal  is  roomy  and  contains  the  spinal  cord.  This 
part  of  the  vertebral  column  lies  at  a  considerable  depth  from  the 
surface,  and  is  well  protected  by  the  overlying  muscles. 

The  Side  of  the  Neck. — This  region  is  quadrilateral;  bounded 
above  by  the  lower  border  of  the  jaw-bone  and  an  imaginary  line 
drawn  from  the  angle  of  the  jaw  to  the  mastoid  process;  below,  by 
the  clavicle;  in  front,  by  the  middle  line  of  the  neck;  and,  behind, 
by  the  anterior  border  of  the  trapezius.  It  is  divided  into  two  tri- 
angles— an  anterior  and  a  posterior — by  the  sterno-mastoid  muscle. 

The  sterno-mastoid  muscle  is  a  most  important  surgical  land- 
mark. It  is  attached  above  to  the  mastoid  process  and  the  adjacent 
part  of  the  occipital  bone;   below,  to  the  inner  end  of  the  clavicle 


SURGICAL  ANATOMY  OF  THE  NECK.  121 

and  the  upper  end  of  the  sternum.  This  muscle  not  only  divides 
the  side  of  the  neck  into  an  anterior  and  a  posterior  triangle,  hut, 
being  a  broad  muscle  itself,  covers  important  structures  not  seen  in 
either  of  the  triangles;  therefore  in  addition  to  the  triangles  one 
might  well  describe  a  sterno-mastoid  region. 

The  side  of  the  neck  is  covered  by  the  skin,  beneath  which  the 
subcutaneous  fat  and  superficial  fascia  are  found,  and,  beneath  these, 
there  is  a  broad,  thin,  muscular  layer:  the  platysma.  This  muscle, 
which  is  spread  out  in  a  thin  sheet,  extends  from  the  lower  border 
of  the  inferior  maxilla  downward  and  backward,  being  continued 
downward  beyond  the  clavicle,  where  it  is  blended  with  the  subcu- 
taneous tissue  of  the  upper  part  of  the  chest.  The  platysma  is  inti- 
mately united  with  the  skin,  and  together  with  it  is  freely  movable 
upon  the  parts  which  lie  beneath  it  and  with  which  it  and  the  skin 
are  united  by  loose  connective  tissue.  It  will  be  observed  that  the 
platysma  does  not  cover  the  anterior  portion  of  the  neck  in  the 
laryngeal  and  tracheal  regions. 

Beneath  the  superficial  fascia  and  the  platysma — i.e.,  between 
these  and  the  deep  cervical  fascia — are  found  the  external  and  ante- 
rior jugular  veins  together  with  some  nervous  branches  which  are 
derived  from  the  cervical  plexus  and  from  the  facial. 

The  External  Jtjgulak  Vein,  during  efforts  of  straining  and 
in  conditions  of  obstructed  venous  return,  may  become  distended 
and  sufficiently  prominent  to  be  recognized  beneath  the  skin.  This 
vessel  is  formed  above,  behind  the  angle  of  the  jaw,  by  the  junction 
of  the  posterior  auricular  vein  and  the  posterior  branch  of  the  tem- 
poro-maxillary  vein;  it  passes  straight  down  the  side  of  the  neck, 
crossing  the  sterno-mastoid  muscle  from  its  anterior  to  its  posterior 
border,  and,  below,  pierces  the  deep  cervical  fascia,  just  above  the 
clavicle  and  behind  the  attachment  of  the  sterno-mastoid  to  this 
bone,  to  empty  into  the  subclavian.  After  it  pierces  the  deep  cervical 
fascia  and  before  it  terminates  in  the  subclavian,  which  it  does  just 
external  to  the  tendon  of  the  scalenus  anticus,  it  receives  the  supra- 
scapular, transverse  cervical,  and  anterior  jugular  veins. 

The  Anterior  Jugular  Vein. — This  is  formed  in  the  hyoid 
region  by  the  junction  of  several  veins  from  the  upper  anterior  part 
of  the  neck,  and  passes  downward,  anterior  to  the.edge  of  the  sterno- 
mastoid  muscle,  between  the  superficial  fascia  and  platysma  and  the 
deep  cervical  fascia;  in  the  lower  part  of  the  neck  it  pierces  the 
anterior  layer  of  the  deep  cervical  fascia  in  front  of  the  sterno- 


122  NECK  AND  TONGUE. 

mastoid  and  then  passes  backward,  beneath  this  muscle,  through 
the  suprasternal  space,  to  join  the  external  jugular  just  before  this 
vessel  enters  the  subclavian.  The  external  and  anterior  jugular 
veins  are  often  cut  in  making  incisions  in  the  neck,  but  may  be 
readily  clamped  and  ligated  or  they  may  be  recognized  and  ligated 
before  they  are  cut. 

The  Nerves  that  are  found  in  this  part  of  the  neck  beneath 
the  superficial  fascia  and  platysma  are  some  superficial  ascending 
and  descending  branches  of  the  cervical  plexus  and  descending 
branches  from  the  facial;  these,  however,  are  of  no  special  surgical 
importance. 

The  Anterior  Triangle. — The  base  of  this  triangle  is  above, 
and  corresponds  to  the  lower  border  of  the  jaw  and  an  imaginary  line 
drawn  from  its  angle  to  the  mastoid  process.  Its  apex  is  below  at 
the  sterno-clavicular  articulation;  its  posterior  border  is  formed  by 
the  anterior  edge  of  the  sterno-mastoid  muscle,  and  its  anterior 
boundary  is  indicated  by  the  middle  line  of  the  neck. 

The  anterior  triangle  is  subdivided  into  an  upper  and  a  lower 
triangle  by  the  anterior  belly  of  the  omo-hyoid;  this  is  a  thin,  double- 
bellied  muscle  that  swings  obliquely  across  the  side  of  the  neck, 
being  attached  above  to  the  hyoid  bone  and  below  and  behind  to  the 
upper  border  of  the  scapula.  The  lower  triangle  is  called  the  in- 
ferior carotid,  and  the  upper,  the  superior  carotid  triangle.  The 
anterior  triangle  presents,  in  its  upper  part,  a  third  triangular  space: 
the  submaxillary  triangle. 

The  Posterior  Triangle. — This  is  the  reverse  of  the  anterior 
triangle.  Its  apex  is  above  at  the  mastoid  process;  its  base,  below, 
is  formed  by  the  clavicle;  its  anterior  border  corresponds  to  the 
posterior  edge  of  the  sterno-mastoid  muscle  and  its  posterior  border 
to  the  anterior  edge  of  the  trapezius.  The  posterior  triangle  is  sub- 
divided by  the  posterior  belly  of  the  omo-hyoid  into  two:  an  upper 
or  occipital  triangle,  and  a  lower  or  subclavian  triangle.  In  order 
to  demonstrate  these  triangles  it  is  necessary  to  draw  the  posterior 
belly  of  the  omo-hyoid  a  little  upward,  as  it  usually  lies  pretty  near 
the  clavicle,  being  fixed  in  this  position,  to  the  first  rib,  by  a  slip 
of  the  deep  cervical  fascia. 

Since  the  sterno-mastoid,  as  already  mentioned,  is  not  a  line, 
but  a  muscle  of  considerable  breadth  and  covers  structures  of  im- 
portance, one  might  describe,  besides  these  triangular  spaces  lying 
in  front  of  and  behind  the  sterno-mastoid  muscle,  a  "sterno-mastoid" 


SUEGICAL  ANATOMY  OF  THE  NECK.  123 

region,  and  we  will  proceed  to  do  this  at  once  and  thus  dispose  of 
it,  and  then  consider  the  triangles  more  in  detail. 

The  Steeno-mastoid  Eegion. — The  sterno-mastoid  region  is. 
covered  by  the  skin  and  fat  (superficial  fascia)  and  to  a  considerable 
extent  by  the  platysrna.  After  removing  these  layers  we  come  down 
upon  the  surface  of  the  muscle  covered  by  the  deep  portion  of  the 
superficial  cervical  fascia.  The  fibers  of  the  muscle  have  an  oblique 
direction  from  above  downward  and  forward,  and  it  is  crossed  from 
above  downward  by  the  external  jugular  vein. 

To  examine  the  structures  that  lie  beneath  the  sterno-mastoid, 
we  may  divide  the  muscle  through  its  middle  and  reflect  either  end. 
Then,  after  cutting  through  the  deep  cervical  fascia,  there  are  ex- 
posed the  deep  muscles  which  lie  beneath  the  sterno-mastoid  and 
which  are  connected  with  the  vertebral  column,  the  longus  colli, 
scaleni,  levator  anguli  scapulas,  etc.,  the  cervical  plexus  of  nerves, 
the  carotid  vessels,  internal  jugular  vein,  etc.,  and  numerous  lym- 
phatic glands. 

The  Lstfeeioe  Cabotid  Teiangle. — This  triangle  is  bounded 
in  front  by  the  middle  line  of  the  neck,  above  and  behind  by  the 
anterior  belly  of  the  omo-hyoid,  below  and  behind  by  the  anterior 
border  of  the  sterno-mastoid.  " 

This  triangle  contains  the  larynx,  trachea,  thyroid  gland,  and 
oesophagus.  These  structures  are  partly  covered  over  and  concealed 
by  the  sterno-hyoid,  sterno-thyroid,  and  thyro-hyoid1  muscles. 

The  oesophagus,  which  projects  well  beyond  the  left  border  of 
the  trachea,  is  more  accessible  in  the  left  triangle  than  in  the  right. 
Ascending  in  the  recess  between  the  trachea  and  the  oesophagus  is 
the  recurrent  laryngeal  nerve;  this  nerve  enters  the  larynx  between 
the  thyroid  and  cricoid  cartilages,  behind  the  articulation  of  these 
two  cartilages.  Lying  to  the  outer  side  of  these  structures  (larynx, 
trachea,  and  oesophagus)  are  the  common  carotid  artery,  with  the 
internal  jugular  vein  upon  its  outer  side,  and  the  pneumogastric 
nerve  between  them,  but  on  a  plane  posterior.  The  middle  thyroid 
vein  passes  outward  across  this  space  to  enter  the  internal  jugular 
vein,  passing  across  the  front  of  the  common  carotid  artery  to  reach 
its  destination. 

In  this  triangle  the  common  carotid  artery  and  the  internal 
jugular  vein  lie  beneath  the  anterior  border  of  the  sterno-mastoid 


1  The  thyro-hyoid  is  really  the  continuation  of  the  sterno-thyroid. 


124 


NECK  AND  TONGUE. 


Fig.  75.— Side  of  Neck  to  Show  Triangles.  DA,  anterior  belly  of  the 
digastric;  DP,  posterior  belly  of  the  digastric;  EJ,  external  jugular  vein; 
F,  facial  vein;  HO,  hyo-glossus  muscle;  BY,  hypoglossal  nerve;  IJ,  internal 
jugular  vein;  M.H,  mylo-hyoid  muscle;  OH  A,  anterior  belly  of  the  omo- 
hyoid; OHP,  posterior  belly  of  the  omo-hyoid;  PA,  post-auricular  vein;  PJ, 
posterior  jugular  vein;  8 A,  scalenus  anticus  muscle;  80,  subclavian  artery; 
8.TY,  sterno-thyroid  muscle;   T,  temporal  vein. 


SURGICAL  ANATOMY  OF  THE  NECK.  125 

muscle,  which  is  the  guide  to  them  and  which  must  be  drawn  out- 
ward (backward)  in  order  to  expose  them.  Lying  still  deeper  in  this 
part  of  the  neck,  beneath  the  carotid  artery  and  the  internal  jugular 
vein,  are  the  inferior  thyroid  artery,  which  passes  inward  and  upward 
behind  these  vessels  to  reach  the  lower  part  of  the  thyroid  gland, 
and  the  vertebral  artery,  which  enters  the  foramen  in  the  root  of 
the  transverse  process  of  the  sixth  cervical  vertebra.  The  sympa- 
thetic nerve  is  also  found  deep  in  this  space  behind  the  carotid 
vessels,  resting  upon  the  muscles  which  cover  the  front  of  the  ver- 
tebral column,  and  in  this  situation  it  presents  its  middle  cervical 
ganglion. 

The  Superior  Carotid  Triangle.  —  This  space  is  bounded 
behind  by  the  anterior  border  of  the  sterno-mastoid,  above  and  in 
front  by  the  posterior  belly  of  the  digastric  and  the  stylo-hyoid,  and 
below  and  in  front  by  the  anterior  belly  of  the  omo-hyoid.  The 
floor  of  this  space  is  formed  by  the  constrictor  muscles  of  the  phar- 
ynx and  the  thyro-hyoid  and  a  part  of  the  hyo-glossus  muscles.  It 
contains  the  upper  part  of  the  common  carotid  artery  and  its  bifur- 
cation into  the  internal  and  external  carotids,  which  division  occurs 
upon  a  level  with  the  upper  border  of  the  thyroid  cartilage.  The 
internal  jugular  vein  lies  in  close  contact  with  the  outer  side  of  the 
common  carotid  artery  and  its  continuation,  the  internal  carotid; 
and  the  pneumogastric  nerve  still  holds  its  place  between  the  artery 
and  vein,  but  on  a  plane  posterior  to  both. 

The  vessels  in  this  triangle  are  superficial,  not  being  covered 
by  the  anterior  edge  of  the  sterno-mastoid,  but  lying  anterior  to  it. 
The  edge  of  the  muscle  is  here  also  the  guide  to  the  vessels.  A 
chain  of  lymphatic  nodes  is  located  along  the  front  border  of  the 
sterno-mastoid  muscle,  and  some  of  them  are  in  very  close  proximity 
to  the  internal  jugular  vein. 

In  this  triangle,  the  external  carotid,  as  it  ascends  to  a  point 
behind  the  angle  of  the  jaw,  describes  a  slight  curve  with  the  con- 
vexity forward,  and  lies  rather  beneath  the  posterior  belly  of  the 
digastric  and  stylo-hyoid  and  upon  a  plane  anterior  to  the  internal 
carotid,  giving  off  several  important  branches:  among  them  the 
superior  thyroid,  which  passes  to  the  upper  part  of  the  thyroid 
gland;  the  lingual,  which  passes  forward  beneath  the  hyo-glossus 
muscle  to  supply  the  tongue;  and  the  facial,  which  passes  upward 
and  outward  over  the  lower  border  of  the  jaw.  The  occipital  and 
the  posterior  auricular  are  derived  from  the  posterior  aspect  of  the 


126  NECK  AND  TONGUE. 

external  carotid  artery  and  ascend  in  a  direction  upward  and  back- 
ward. 

The  hypoglossal  nerve  arches  forward  across  the  external  carotid 
artery  upon  a  level  with  the  origin  of  the  occipital  artery. 

In  this  space  the  facial  vein  is  joined  by  a  large  branch  from 
the  temporo-maxillary,  and  then  passes  downward  and  outward 
across  the  external  carotid  and  internal  carotid  arteries  to  enter  the 
internal  jugular  vein.  This  vein  is  often  cut  during  extirpation  of 
glands  in  this  triangle  and  gives  rise  to  a  copious  hemorrhage,  which 
is  readily  controlled  by  pressure  with  the  finger  in  the  wound  and 
artery  forceps.  It  may  often  be  recognized  and  tied  double  before  it 
is  cut. 

The  Submaxillaey  Teiangle. — The  submaxillary  triangle  is 
bounded  above  by  the  lower  border  of  the  jaw  and  an  imaginary  line 
drawn  from  the  angle  of  the  jaw  to  the  tip  of  the  mastoid  process, 
below  and  in  front  by  the  anterior  belly  of  the  digastric  muscle,  and 
below  and  behind  by  the  posterior  belly  of  the  digastric  and  the 
stylo-hyoid  muscle.  The  apex  of  the  triangle  corresponds  to  the 
attachment  of  these  muscles  to  the  hyoid  bone.  When  the  coverings 
of  this  triangle — consisting  of  the  skin,  subcutaneous  fat,  platysma, 
and  deep  fascia — are  reflected,  we  find  it  fairly  well  occupied  by  the 
submaxillary  gland,  which  rests  in  a  bed  of  loose  connective  tissue,, 
and  various  lymph-nodes.  The  back  part  of  this  triangle  is  crossed 
by  the  facial  artery,  which  passes  upward  and  forward  over  the  upper 
border  of  the  submaxillary  gland  to  reach  the  lower  border  of  the 
jaw,  over  which  it  curves  on  to  the  side  of  the  face,  grooving  the 
bone  just  in  front  of  the  attachment  of  the  masseter  muscle.  The 
facial  vein,  which  lies  superficial  to  the  facial  artery,  after  receiving 
the  submental  vein,  also  crosses  the  posterior  part  of  the  submaxil- 
lary triangle,  passing  downward  and  backward  across  (superficial  to) 
the  posterior  belly  of  the  digastric  and  stylo-hyoid  muscles  and,  after 
uniting  with  a  large  branch  from  the  temporo-maxillary  vein  in  the 
upper  part  of  the  superior  carotid  triangle,  enters  the  internal 
jugular. 

After  the  submaxillary  gland  has  been  raised  out  of  its  bed,  its 
duct,  Wharton's,  may  be  seen  passing  forward  beneath  the  posterior 
edge  of  the  mylo-hyoid  muscle  to  open  anteriorly  in  the  floor  of  the 
mouth.  The  gland  may  be  isolated  and  cut  away  from  its  duct,  and 
then"  the  floor  of  the  triangle  is  exposed  to  view.  The  floor  of  the 
triangle  is  formed,  for  the  most  part,  by  the  mylo-hyoid  muscle, 


SURGICAL  ANATOMY  OF  THE  NECK.  12? 

whose  fibers  have  an  oblique  direction,  and  the  hyo-glossus,  which 
lies  upon  a  deeper  plane  than  the  mylo-hyoid  and  forms  the  posterior 
part  of  the  floor  of  the  triangle;  the  fibers  of  the  hyo-glossus  muscle 
run  straight  up  and  down  from  the  hyoid  bone  to  the  under  surface  of 
the  tongue.  The  lingual  artery  lies  beneath  the  hyo-glossus  muscle. 
The  submental  branch  of  the  facial  artery  passes  forward  parallel 
with  and  close  to  the  inner  surface  of  the  body  of  the  jaw,  resting 
upon  the  mylo-hyoid  muscle.  The  hypoglossal  nerve  may  be  seen 
passing  forward,  entering  the  submaxillary  triangle  from  beneath  the 
posterior  belly  of  the  digastric  muscle.  In  the  triangle  this  nerve 
rests  upon  the  hyo-glossus  muscle,  disappearing  anteriorly  beneath 
the  posterior  border  of  the  mylo-hyoid  muscle.  Accompanying  the 
hypoglossal  nerve  is  the  lingual  vein,  which  passes  backward  and 
enters  the  facial. 

The  hypoglossal  nerve  forms  the  base  of  a  second  smaller  tri- 
angle, which  corresponds  to  the  apex  of  the  submaxillary  triangle 
and  which  is  called  the  lingual  triangle. 

The  Lingual  Teiangle. — The  base  of  the  lingual  triangle, 
which  is  above,  is  formed  by  the  hypoglossal  nerve;  its  borders, 
anterior  and  posterior,  by  the  respective  bellies  of  the  digastric. 
The  apex  of  the  triangle  is  located  beloAV  where  this  muscle  is  at- 
tached to  the  hyoid  bone.  The  floor  of  the  triangle  is  formed  by 
the  fibers  of  the  hyo-glossus  muscle.  Directly  beneath  this  muscle, 
in  the  space  marked  out  as  the  lingual  triangle,  the  lingual  artery 
is  located,  and  in  this  situation  it  is  very  readily  found  and  ligated. 
The  hyo-glossus  muscle  is  picked  up  with  mouse-tooth  forceps  and 
snipped  through,  when  the  lingual  artery  comes  into  plain  view  and 
may  be  easily  surrounded  with  a  ligature  in  a  carrier. 

The  Occipital  Triangle. — This  space  is  bounded  in  front  by 
the  posterior  border  of  the  sterno-mastoid,  behind  by  the  anterior 
border  of  the  trapezius,  and  below  by  the  posterior  belly  of  the  omo- 
hyoid. This  triangle  is  of  but  little  surgical  importance.  It  is  cov- 
ered by  the  skin,  superficial  fascia  (fat),  by  the  platysma  in  part, 
and  by  the  deep  cervical  fascia.  Beneath  the  deep  cervical  fascia 
there  is  a  mass  of  loose  fat.  Lying  upon  the  deep  fascia  (superficial 
to  it)  is  the  posterior  jugular  vein,  which,  below,  at  the  posterior 
border  of  the  sterno-mastoid  muscle,  joins  the  external  jugular.  A 
chain  of  lymphatic  nodes,  which  lie  along  the  posterior  border  of 
the  sterno-mastoid  in  this  triangle,  are  frequently  diseased  and  re- 
quire removal.     The  space  is  crossed  by  the  superficial  descending 


128  NECK  AND  TONGUE. 

branches  of  the  cervical  plexus.  The  spinal  accessory  nerve  emerges 
from  the  posterior  border  of  the  sterno-mastoid,  at  the  junction  of 
its  upper  and  middle  thirds,  and  passes  obliquely  downward  and 
backward  across  this  space,  beneath  the  deep  cervical  fascia,  and 
disappears  under  the  anterior  border  of  the  trapezius  muscle,  which 
it  supplies.  The  floor  of  this  space  is  formed,  from  above  downward, 
by  the  splenius,  the  levator  anguli  scapulse,  and  the  middle  and 
posterior  scaleni. 

The  Subclavian"  Triangle. — This  triangle  corresponds  to  the 
lower  part  of  the  posterior  triangle.  It  is  covered  by  the  skin,  fat, 
and  superficial  fascia,  the  platysma,  and  deep  cervical  fascia,  and  is 
crossed  by  the  superficial  descending  branches  of  the  cervical  plexus. 
In  the  front  part  of  this  space,  just  behind  the  posterior  border  of 
the  sterno-mastoid  muscle,  the  external  jugular  vein  pierces  the  deep 
cervical  fascia.  After  the  integument,  etc.,  including  the  deep  cer- 
vical fascia,  have  been  incised,  the  boundaries  of  the  subclavian  tri- 
angle may  be  sought  for.  These  are,  below,  the  clavicle;  in  front,  the 
posterior  border  of  the  sterno-mastoid  muscle;  and,  above,  the  poste- 
rior belly  of  the  omo-hyoid;  this  latter  muscle  lies  low  in  the  neck, 
close  to  the  clavicle,  and  in  order  to  demonstrate  the  triangle  it  may 
be  necessary  to  draw  it  somewhat  upward. 

Crossing  the  space  from  without  inward,  just  above  the  clavicle, 
are  the  transversalis  colli  and  suprascapular  veins;  these  form  a 
plexus  beneath  the  deep  cervical  fascia  and  terminate  in  the  ex- 
ternal jugular;  the  external  jugular  vein  enters  the  subclavian 
just  external  to  the  tendon  of  the  scalenus  anticus.  The  external 
jugular  vein,  after  piercing  the  deep  cervical  fascia  and  immedi- 
ately before  it  terminates  in  the  subclavian,  also,  as  a  rule,  receives 
the  anterior  jugular  vein.  This  latter  drains  the  front  of  the  neck, 
originating  above  in  the  hyoid  and  suprahyoid  regions.  In  the 
subclavian  triangle  there  is  also  found  (beneath  the  deep  cervical 
fascia)  a  mass  of  lymphatic  nodes,  fat,  and  loose  connective  tissue 
which  communicates  with  the  lymphatics  of  the  breast  and  axilla 
and  which  may  become  involved  in  disease  of  the  breast.  The  floor 
of  the  subclavian  triangle  is  formed  by  the  scalenus  anticus  and 
scalenus  medius  muscles.  In  order  to  expose  the  scalenus  anticus 
muscle,  the  sterno-mastoid,  which  conceals  it,  must  be  drawn  forward 
(inward).  When  the  scalenus  anticus  is  thus  exposed  the  phrenic 
nerve  may  be  seen  passing  obliquely  downward  and  inward  across 
its  anterior  surface,  descending  into  the  chest  across  the  front  of 


SURGICAL  ANATOMY  OF  THE  NECK.  129 

the  first  part  of  the  subclavian  artery.  Beneath  the  venous  plexus 
above  mentioned,  and  lying  close  upon  the  muscles  that  form  the 
floor  of  the  triangle,  are  the  transversalis  colli  and  suprascapular 
arteries:  branches  from  the  first  part  of  the  subclavian.  Emerging 
from  between  the  scalenus  anticus  and  the  scalenus  medius  and 
passing  obliquely  downward  and  outward  are  the  three  cords  of  the 
brachial  plexus.  They  disappear  beneath  the  clavicle  into  the  axil- 
lary space.  The  third  part  of  the  subclavian  artery  is  found  below 
the  cords  of  the  brachial  plexus,  deep  in  the  subclavian  triangle, 
below  the  level  of  the  clavicle,  resting  in  the  groove  upon  the  upper 
surface  of  the  first  rib,  external  to  the  attachment  of  the  tendon  of 
the  scalenus  anticus.  The  tendon  of  the  scalenus  anticus  is  the 
guide  to  the  artery,  and  is  readily  recognized  in  the  inner  or  forward 
part  of  the  subclavian  triangle  as  a  tense  cord  and  may  be  followed 
downward  with  the  finger  as  far  as  its  attachment  to  the  first  rib. 
The  subclavian  vein  lies  some  distance  away  from  the  artery  in  front 
of,  and  internal  to  it,  the  artery  and  vein  being  separated  from  each 
other  by  the  tendon  of  the  scalenus  anticus. 

As  the  subclavian  artery  emerges  from  the  chest  it  arches  out- 
ward and  forward  to  reach  the  first  rib.  That  portion  of  the  sub- 
clavian which  lies  behind  the  tendon  of  the  scalenus  anticus  is  the 
second  part  of  the  artery;  the  part  which  lies  to  the  inner  side  of 
this  tendon  is  the  first  part;  and  that  which  lies  external  to  the 
tendon  of  the  scalenus  anticus,  resting  upon  the  upper  surface  of 
the  first  rib,  is  the  third  part  of  the  artery:  the  part  that  is  usually 
ligated.  The  second  and  first  parts  of  the  subclavian  artery,  the  parts 
behind  and  internal  to  the  tendon  of  the  scalenus  anticus,  are  in 
direct  relation  with  the  dome  of  the  pleura  and  the  apex  of  the 
lung,  which  projects  upward  into  the  root  of  the  neck,  beneath  the 
scaleni  muscles,  for  a  distance  of  3  to  3  1/2  cm.  above  the  level  of 
the  clavicle.  In  tying  the  third  part  of  the  subclavian  artery  one 
should  not  mistake  for  it  one  of  the  cords  of  the  brachial  plexus, 
which  lie  above.  The  artery  is  deep,  and  rests  directly  upon  the  first 
rib.  The  subclavian  vein  is  pretty  well  separated  from  the  artery, 
lying  in  front  of  and  internal  to  it  and  upon  a  rather  lower  level 
than  the  artery.  By  drawing  the  shoulder  down  we  depress  the 
clavicle,  and  may  thus  make  the  artery  more  accessible. 

The  Front  of  the  Neck. — This  part  of  the  neck  may  be  divided 
into  the  suprahyoid  region,  the  part  above  the  hyoid  bone,  and  the 
infrahyoid  region,  the  part  below  the  hyoid  bone.     The  infrahyoid 


130  NECK  AND  TONGUE. 

region  presents  for  consideration  the  larynx,  trachea,  and  thyroid 
gland,  and  the  oesophagus,  which  lies  behind  these. 

The  Hyoid  Bone. — This  is  a  horseshoe-  or  IT-  shaped  hone, 
with  a  body  and  two  lateral  horns,  which  are  prolonged  backward, 
one  on  either  side,  and  two  lesser  horns,  directed  upward. 

In  the  natural  position  of  the  head  the  hyoid  bone  is  on  a  level 
with  the  lower  border  of  the  inferior  maxillary  bone,  and  is  not  dis- 
tinctly recognized  until  the  head  is  thrown  back.  It  is  not  station- 
ary, but  may  be  said  to  be  about  opposite  the  fourth  cervical  ver- 
tebra. To  it  are  attached  numerous  muscles,  coming  from  different 
directions.  To  the  upper  surface  of  its  body  is  attached  the  base  or 
root  of  the  tongue;  from  its  lower  border  is  suspended  the  larynx. 
The  epiglottis  is  placed  behind  the  body  of  the  bone,  and  is  attached 
to  its  posterior  surface.  To  the  upper  surface  of  its  lateral  horn 
is  attached  the  middle  constrictor  of  the  pharynx,  and  it  thus  serves 
to  support  the  wall  of  the  pharynx  and  provide  a  fixed  point  for 
the  action  of  the  muscles  in  deglutition. 

Supeahyoid  Kegion. — This  is  the  space  between  the  hyoid  bone 
and  the  lower  border  of  the  jaw.  This  region  is  covered  with  skin, 
superficial  fascia  (fat),  platysma,  and  deep  fascia;  the  deep  fascia  is 
attached  to  the  body  and  cornua  of  the  hyoid  bone.  Beneath  the 
platysma,  between  it  and  the  deep  fascia,  are  several  venous  branches 
which  go  to  form  the  anterior  jugular.  Upon  removal  of  the  deep 
fascia  a  triangular  space  is  exposed:  the  submental  triangle.  The 
apex  of  this  triangle  corresponds  to  the  symphysis  of  the*  lower  jaw, 
its  sides  to  the  anterior  belly  of  either  digastric,  and  its  base  to  the 
hyoid  bone.  Its  floor  consists  of  the  mylo-hyoid  muscle,  with  its 
raphe  in  the  middle  line.  This  space  contains,  beneath  the  deep 
fascia,  several  lymphatic  nodes,  which  are  occasionally  the  seat  of 
disease  and  may  demand  extirpation.  Beneath  the  mylo-hyoid,  upon 
either  side,  in  the  floor  of  the  mouth,  the  sublingual  glands  are 
lodged.  The  floor  of  this  space  is,  at  times,  cut  through  in  opera- 
tions upon  the  lower  jaw  and  in  order  to  reach  the  tongue. 

Infrahyoid  Eegion. — This  is  the  region  below  the  hyoid  bone. 
The  skin  is  but  loosely  attached  to  the  underlying  structures;  be- 
neath the  skin  are  fat  and  the  deep  cervical  fascia.  The  platysma 
is  not  met  with  in  this  part  of  the  neck.  Below  the  hyoid  bone  may 
be  felt  the  thyroid  cartilage,  that  of  either  side  uniting  in  the  middle, 
line  "to  form  the  prominence  "Adam's  apple."  The  Adam's  apple 
is  not  prominent  in  the  female  or  child,  and  is  not,  therefore,  a  good 


SURGICAL  ANATOMY  OF  THE  NECK. 


131 


surgical  guide.  Below  the  thyroid  the  cricoid  cartilage  may  be  felt. 
This  is  located  opposite  the  sixth  cervical  vertebra,  and  marks  the 
point  where "  the   omo-hyoid  muscle   crosses   the   common   carotid 


Fig.  76.— Front  of  the  Neck.  GO,  cricoid  cartilage;  DA,  anterior  belly  of 
digastric;  E,  hyoid  bone;  MH,  mylo-hyoid  muscle;  SH,  sterno-hyoid  muscle; 
S.T7,  sterno-thyroid  muscle;  TO,  thyroid  cartilage;  TR,  trachea;  TY.O, 
isthmus  of  thyroid  gland. 


132  NECK  AND  TONGUE. 

artery.  The  cricoid  is  a  ring  of  cartilage  which  is  rather  narrow 
anteriorly,  but  of  considerable  breadth  posteriorly;  it  is  always 
very  readily  felt,  and  is  therefore  a  good  guide.  From  the  cricoid 
down  to  the  upper  border  of  the  sternum  the  space  is  occupied 
by  the  trachea.  Above,  at  its  commencement  at  the  cricoid  carti- 
lage, the  trachea  is  quite  superficial,  lying  just  beneath  the  integu- 
ment; but  lower  down  it  gets  to  lie  deeper,  farther  away  from 
the  surface,  and  is  less  accessible.  Just  below  the  cricoid  cartilage 
the  isthmus  of  the  thyroid  gland  lies  transversely  across  the  front 
of  the  trachea,  each  lobe  of  the  gland  extending  outward  and  upward 
beneath  the  sterno-hyoid  and  sterno-thyroid  muscles,  reaching  up- 
ward upon  the  side  of  the  thyroid  cartilage  and  getting  into  close 
proximity  to  the  common  carotid  artery  and  its  adjoining  structures. 
Between  the  cricoid  cartilage  and  the  isthmus  of  the  thyroid  gland 
there  is  usually  a  space  about  one-half  inch  wide.  On  either  side 
of  the  middle  line,  passing  from  the  hyoid  bone  and  thyroid  carti- 
lage down  to  the  sternum,  are  two  long,  flat,  ribbon-like  muscles, 
one  superimposed  upon  the  other:  the  sterno-hyoid  and  sterno- 
thyroid. The  sterno-thyroid  lies  beneath  the  sterno-hyoid,  being 
partly  concealed  by  the  latter.  The  sterno-thyroid  is  attached  to 
the  side  of  the  thyroid  cartilage  and  does  not  reach  the  hyoid  bone, 
but  is  continuous  with  the  short  thyro-hyoid  muscle,  which  is  at- 
tached to  the  hyoid  bone.  The  attachments  of  these  muscles  are 
indicated  by  their  names.  The  inner  edges  of  these  muscles  do  not 
meet  in  the  middle  line  of  the  neck,  but  are  connected  with  each 
other  through  the  intervening  deep  cervical  fascia.  They  partly 
cover  the  trachea  and  sides  of  the  larynx  and  the  lateral  lobes  of 
the  thyroid  gland.  Between  the  edges  of  the  muscles,  in  the  middle 
line,  from  above  downward,  and  covered  only  by  the  interposed  deep 
fascia,  are  the  thyroid  and  cricoid  cartilages,  the  isthmus  of  the 
thyroid  gland,  and  the  trachea. 

Between  the  hyoid  bone  and  the  upper  border  of  the  thyroid 
cartilage  there  is  a  space  which  is  filled  in  by  the  thyro-hyoid  mem- 
brane. This  membrane  is  pierced  on  either  side  by  the  superior 
laryngeal  vessels  and  the  internal  laryngeal  branches  of  the  supe- 
rior laryngeal  nerve.  This  membrane  may  be  cut  in  attempts  at 
suicide:  cut  throat.  Between  the  lower  border  of  the  thyroid  carti- 
lage" and  the  upper  border  of  the  cricoid  there  is  also  a  space  which 
is  filled  in  by  a  membrane:  the  crico-thyroid.  This  may  also  be 
divided  in  cut  throat.    Above  the  hyoid  bone,  running  transversely 


SURGICAL  ANATOMY  OF  THE  NECK.  133 

inward  and  anastomosing  with  the  hranch  of  the  opposite  side,  is 
the  hyoid  branch  of  the  lingual  artery.  Below  the  hyoid  bone  there 
is  a  similar  transverse  branch,  the  hyoid,  which  is  derived  from  the 
superior  thyroid  and  which  passes  likewise  inward,  anastomosing 
across  the  middle  line  with  its  fellow  of  the  opposite  side.  A  third 
transverse  branch  passes  inward,  above  the  cricoid  cartilage,  upon 
the  membrane  between  the  lower  border  of  the  thyroid  cartilage 
and  upper  border  of  the  cricoid  cartilage.  This  is  the  crico-thyroid 
branch  of  the  superior  thyroid  artery.  It  also  anastomoses  with  its 
fellow  of  the  opposite  side.  Below  the  level  of  the  cricoid  cartilage 
no  arterial  branches  cross  the  middle  line  except  through  the  isth- 
mus of  the  thyroid  gland. 

The  oesophagus  lies  behind  the  trachea,  closely  applied  to  its 
posterior  wall,  and  when  empty  is  flattened  out  against  the  vertebrse. 
It  projects  a  considerable  distance  to  the  left  of  the  trachea,  and 
is  therefore  easier  to  reach  through  an  incision  upon  the  left  side 
of  the  neck  than  upon  the  right.  Above,  the  oesophagus  is  con- 
tinuous with  the  pharynx,  into  the  commencement  of  which  the 
larynx  opens,  the  orifice  of  the  larynx  being  protected  by  the  over- 
hanging epiglottis,  which  is  situated  below  and  behind  the  root  of 
the  tongue.  The  posterior  wall  of  the  larynx,  which  is  formed  by 
the  broad  posterior  portion  of  the  cricoid  cartilage,  is  in  close  rela- 
tion with  the  front  wall  of  the  pharynx.  Only  a  thin  layer  of  con- 
nective tissue  intervenes  between  the  anterior  wall  of  the  pharynx, 
which  consists  merely  of  a  layer  of  mucous  membrane,  and  the 
posterior  part  of  the  larynx,  which  is  made  up  chiefly  of  the  broad 
posterior  part  of  the  cricoid  cartilage.  When  the  pharynx  is  empty 
it  is  flattened  out  against  the  vertebral  column,  and  the  larynx,  under 
these  circumstances,  also  lies  close  to  the  vertebral  column. 

From  the  cricoid  cartilage  down,  the  oesophagus  and  trachea, 
although  in  close  proximity  to  each  other,  form  two  distinct  tubes, 
which  may  be  readily  separated,  one  from  the  other.  The  posterior 
wall  of  the  trachea,  which  is  in  direct  relation  with  the  oesophagus, 
is  devoid  of  cartilaginous  bands,  and  therefore  a  foreign  body,  lodged 
in  the  eesophagus,  might  press  upon  this  contiguous,  non-carti- 
laginous portion  of  the  wall  of  the  trachea  and  cause  symptoms  of 
strangulation.  In  the  recess  between  the  trachea  and  oesophagus, 
on  either  side,  the  recurrent  laryngeal  nerve  ascends  to  enter  the 
lower  back  part  of  the  larynx  behind  the  articulation  which  exists 
between  the  cricoid  and  thyroid  cartilages. 


134  NECK  AND  TONGUE. 

The  Laryngeal  Kegion  is  covered  in  front  by  skin  and  deep 
fascia,  but  laterally  by  the  muscles,  the  sterno-hyoid  and  sterno- 
thyroid and  thyro-hyoid,  and  by  the  lobes  of  the  thyroid  gland. 

The  interior  of  the  larynx  may  be  examined  after  splitting  the 
thyroid  cartilage,  taking  care  to  make  this  section  in  the  midle  line, 
between  the  anterior  attachments  of  the  vocal  cords.  The  true  and 
false  vocal  cords  are  then  exposed  to  view.  The  true  cords  are  the 
lower,  and  are  attached  anteriorly,  upon  either  side  of  the  middle 
line,  to  the  thyroid  cartilage,  midway  between  the  lowest  part  of  the 
ineisura  in  its  upper  border  and  the  lower  border;  posteriorly  the 
true  vocal  cords  are  attached  to  the  arytenoid  cartilages,  which  rest, 
swivel-like,  upon  the  upper  surface  of  the  cricoid  cartilage. 

The  false  vocal  cords  are  the  loose  folds  of  mucous  membrane 
which  are  situated  above  the  true  cords,  inclosing  much  loose  con- 
nective tissue;  these  may  readily  become  cedematous — oedema  glottis 
— and  act  as  a  dangerous  obstruction  to  respiration. 

The  Thyroid  Gland. — The  isthmus  is  the  narrowest  part  of 
the  thyroid  gland.  It  joins  the  two  lobes  of  the  gland  across  the 
middle  line,  resting  transversely  upon  the  upper  part  of  the  trachea. 
At  times  there  projects  from  the  upper  border  of  the  isthmus  a 
process  of  glandular  tissue,  which  is  located  in  front  of  the  larynx 
and  which  may  be  encountered  in  operations  in  this  locality.  The 
thyroid  gland  is  fixed  to  the  cricoid  and  thyroid  cartilages  by  bands 
of  connective  tissue.  These  bands  connect  the  isthmus  of  the  gland 
to  the  cricoid  cartilage  and  the  lateral  lobes,  adjacent  to  the  isthmus, 
to  the  sides  of  the  thyroid  cartilage.  It  is  necessary  to  divide  those 
bands  that  connect  the  isthmus  to  the  cricoid  cartilage  before  the 
isthmus  can  be  dislocated  downward  in  order  to  expose  the  upper 
rings  of  the  trachea  in  performing  the  operation  of  high  trache- 
otomy. The  two  lobes  of  the  thyroid  gland,  one  on  each  side,  are 
prolonged  backward  and  upward  upon  the  sides  of  the  trachea  and 
larynx,  reaching  as  far  back  as  the  oesophagus  and  thus  getting  into 
close  relationship  with  the  common  carotid  artery  and  its  adjacent 
structures.  As  the  recurrent  laryngeal  nerve  of  each  side  ascends 
between  the  trachea  and  oesophagus  to  enter  the  lower,  posterior  part 
of  the  larynx  it  lies  beneath  the  corresponding  lateral  lobe  of  the 
thyroid  gland.  The  isthmus  of  the  thyroid  lies  just  beneath  the  skin 
and  deep  fascia,  whereas  the  lateral  lobes  extend  upward  and  back- 
ward underneath  the  sterno-hyoid  and  sterno-thyroid  muscles. 

On  account  of  the  intimate  relationship  that  exists  between  the 


SURGICAL  ANATOMY  OF  THE  NECK.  135 

thyroid  gland  and  the  trachea,  tumors  involving  the  gland  may- 
press  upon  the  trachea  and  push  it  to  one  side;  so  that  if  trache- 
otomy becomes  necessary  in  these  cases  it  may  be  difficult  to  locate 
the  trachea.  When  the  thyroid  is  enlarged  by  tumors,  etc.,  it  may 
be  seen  to  rise  and  fall  with  the  larynx  in  movements  of  swallowing. 
The  thyroid  is  supplied  by  the  superior  and  inferior  thyroid  arteries 
of  each  side,  and  drained  by  the  superior,  middle,  and  inferior  thy- 
roid veins.  At  times  an  arterial  branch  from  the  transverse  portion 
of  the  arch  of  the  aorta  ascends  upon  the  front  of  the  trachea  to 
reach  the  lower  part  of  the  gland:   the  arteria  thyroidea  ima. 

The  Suprasternal  Region  is  the  space  in  the  lower  front  part 
of  the  neck  above  the  upper  border  of  the  sternum  and  limited  on 
either  side  by  the  anterior  border  of  the  sterno-mastoid.  The  sur- 
face shows  a  depression  here  known  as  the  suprasternal  fossa,  or 
fossa  jugularis.  This  region  is  covered  by  the  skin,  beneath  which 
lies  the  deep  cervical  fascia,  which  splits  into  two  layers,  an  anterior 
and  a  posterior;  these  layers  are  attached  below  to  the  anterior  and 
posterior  edges  of  the  upper  border  of  the  sternum,  inclosing  a  space 
— the  suprasternal — between  them  which  is  occupied  by  some  con- 
nective tissue  and  lymphatic  glands.  A  communicating  venous 
branch  which  connects  the  anterior  jugulars  of  either  side  is  also 
included  between  these  two  layers.  The  suprasternal  space  is  shut 
off  from  the  mediastinum  by  the  posterior  layer  of  the  deep  cervical 
fascia,  and  pus  in  this  space  is  thus  hindered  from  breaking  into  the 
mediastinum  and  is  more  apt  to  open  externally  through  the  skin. 
Beneath  the  deep  fascia  lies  the  trachea,  its  anterior  surface  being 
readily  accessible  for  operation.  This  part  of  the  trachea  may  be 
lengthened  by  throwing  the  head  back:  partly  by  drawing  the 
trachea  out  of  the  chest  and  partly  by  stretching  it. 

If  the  trachea  is  incised  transversely  the  wound  gapes,  and,  if 
completely  severed,  it  retracts  into  the  chest  to  such  an  extent  that 
it  may  be  difficult  or  impossible  to  reunite  it.  At  times  the  arteria 
thyroidea  ima  ascends  in  front  of  this  lower  part  of  the  trachea  and 
might  complicate  an  operation  upon  this  part  of  the  tube. 

Descending  obliquely  downward  and  outward,  from  the  lower 
part  of  the  thyroid  gland,  are  the  inferior  thyroid  veins.  These 
enter  the  right  and  left  innominate  veins  or  both  may  enter  the  left 
innominate,  within  the  chest,  behind  the  first  piece  of  the  sternum. 
The  inferior  thyroid  veins  are  large  and  lie  one  on  either  side  of 
the  middle  line.     As  they  descend  they  get  farther  away  from  the 


136  NECK  AND  TONGUE. 

middle  line,  so  that  they  are  not  likely  to  he  encountered  in  the 
operation  of  low  tracheotomy  if  the  incision  is  kept  strictly  in  the 
median  line. 

The  Blood-vessels  of  the  Neck.  The  Common  Caeotid  Akteky. 
— This  vessel  ascends  in  the  neck  from  hehind  the  sterno-clavicular 
articulation  to  the  level  of  the  upper  horder  of  the  thyroid  cartilage, 
where  it  divides  into  the  external  and  internal  carotid.  The  course 
of  the  artery  is  indicated  hy  a  line  drawn  from  the  sterno-clavicular 
articulation  to  a  point  midway  between  the  angle  of  the  jaw  and  the 
mastoid  process.  The  muscular  guide  to  the  artery  is  the  anterior 
border  of  the  sterno-mastoid. 

The  common  carotid  is  crossed  about  the  level  of  the  cricoid 
cartilage  by  the  omo-hyoid  muscle;  so  that  the  lower  part  of  the 
artery  lies  in  the  inferior  carotid  triangle  and  the  upper  part  in 
the  superior  carotid  triangle.  The  artery  is  more  accessible  for 
ligation  in  the  upper  triangle.  In  the  lower  part  of  its  course, 
below  the  omo-hyoid,  the  artery  lies  beneath  the  anterior  edge  of  the 
sterno-mastoid,  whereas  above,  in  the  superior  carotid  triangle,  it 
does  not  lie  beneath  the  edge  of  the  sterno-mastoid,  but  rather  in 
front  of  it,  and  is  here  quite  superficial,  being  covered  only  by  the 
integument,  platysma,  and  deep  cervical  fascia.  Opposite  the  thy- 
roid cartilage  the  lateral  lobe  of  the  thyroid  gland  comes  into  close 
relation  with  the  artery,  the  latter  grooving  the  gland.  In  its  course 
up  the  neck  the  artery  is  accompanied  by  the  internal  jugular  vein, 
which  lies  close  upon  its  outer  side,  and  by  the  pneumogastric  nerve, 
which  lies  between  the  vein  and  the  artery,  but  on  a  plane  posterior 
to  both.  These  structures  are  lodged  in  a  loose,  connective-tissue 
bed,  which  is  continuous  below  with  the  connective  tissue  of  the 
mediastinum. 

Upon  the  front  of  the  artery,  opposite  the  middle  of  the  thy- 
roid cartilage,  the  descendens  and  communicans  noni  form  a  loop 
from  which  some  branches  are  given  off  to  supply  the  depressor  mus- 
cles of  the  hyoid  bone.  Posteriorly  the  artery  rests  upon  the  trans- 
verse processes  of  the  lower  cervical  vertebras  and  the  attachments 
of  the  vertebral  muscles.  The  sympathetic  nerve  lies  behind  the 
artery  and  is  united  rather  closely  to  the  fascia  that  covers  the  pre- 
vertebral muscles.  Below,  opposite  the  sixth  cervical  vertebra,  the 
inferior  thyroid  artery,  which  arises  from  the  first  part  of  the  sub- 
clavian, curves  inward,  behind  the  carotid,  etc.,  to  reach  the  lower 
part  of  the  thyroid  gland.     To  the  inner  side  of  the  artery  are  the 


SURGICAL  ANATOMY  OF  THE  NECK.  137 

trachea  and  oesophagus,  and,  higher  up,  the  larynx  and  the  lower 
part  of  the  pharynx.  The  larynx  projects  forward  between  the 
arteries  of  either  side.  Ascending  between  the  trachea  and  the 
oesophagus  is  the  inferior,  recurrent,  laryngeal  nerve.  Opposite  the 
thyroid  cartilage  the  artery,  as  mentioned  above,  is  in  close  relation 
with  the  lateral  lobe  of  the  thyroid  gland.  Upon  the  outer  side  of 
the  artery  the  internal  jugular  vein  is  situated,  and  in  close  proxim- 
ity to  the  vein  a  chain  of  lymphatic  nodes.  The  common  carotid 
artery  is  crossed  above  the  omo-hyoid  muscle  by  the  superior  thyroid 
vein  and  about  its  middle — i.e.,  below  the  omo-hyoid — by  the  middle 
thyroid  vein.  Both  these  veins  terminate  in  the  internal  jugular. 
Lower  in  the  neck  the  artery  is  crossed  by  the  anterior  jugular  vein, 
which,  as  a  rule,  terminates  in  the  external  jugular. 

The  artery  is  covered  by  the  integument,  superficial  fascia, 
platysma,  and  deep  fascia.  The  lower  part  of  the  artery  lies  beneath 
the  sterno-mastoid,  and  this  muscle  must  therefore  be  drawn  aside 
in  order  to  expose  the  vessel.  Above,  upon  a  level  with  the  thyroid 
cartilage,  the  artery  lies  quite  superficial,  not  being  overlapped  by 
the  sterno-mastoid,  but  in  front  of  it  and  here  its  pulsation  may  be 
both  felt  and  seen. 

The  Inteenal  Caeotid  is  continued  upward  in  the  same  course 
as  the  common  carotid,  lying  alongside  of  the  pharynx.  The  internal 
jugular  vein  lies  along  its  outer  side,  and  the  pneumogastric  nerve 
lies  between  both,  but  on  a  plane  posterior.  At  the  base  of  the  skull 
the  artery  enters  the  carotid  canal  in  the  petrous  portion  of  the 
temporal  bone,  and  after  traversing  this  canal  enters  the  cranium 
through  the  middle  lacerated  foramen.  In  the  neck  the  internal 
carotid  lies  in  the  superior  carotid  triangle,  covered  by  the  anterior 
edge  of  the  sterno-mastoid;  it  is  situated  deeper  than  the  external 
carotid  and  upon  a  plane  posterior  to  it.  The  stylo-glossus  and  stylo- 
pharyngeus  muscles,  as  they  pass  forward  to  the  tongue  and  to  the 
side  of  the  pharynx,  are  interposed  between  the  internal  and  ex- 
ternal carotids.  Behind,  the  artery  rests  upon  the  transverse  proc- 
esses of  the  upper  cervical  vertebra?  and  upon  the  rectus  capitis 
anticus  major  muscle.  The  sympathetic  nerve,  with  its  superior 
ganglion,  lies  behind  the  artery,  between  it  and  the  anterior  ver- 
tebral muscles.  Internally  the  artery  is  in  relation  with  the  side  of 
the  pharynx.  The  superior  laryngeal  nerve  descends  between  it  and 
the  pharynx.  At  its  origin  the  artery  lies  quite  superficial,  being 
covered  by  the  integument,  platysma,  and  deep  fascia  and  over- 


138  NECK  AND  TONGUE. 

Japped  by  the  anterior  margin  of  the  sterno-mastoid  muscle.  In  the 
upper  part  of  its  course  it  lies  deep  in  the  neck  beneath  the  poste- 
rior belly  of  the  digastric  and  stylo-hyoid  muscles  and  the  parotid 
gland  and  the  stylo-pharyngeus  and  stylo-glossus  muscles,  these  two 
latter  muscles  separating  it  from  the  external  carotid. 

At  the  base  of  the  skull  the  internal  jugular  vein  leaves  the  in- 
ternal carotid  artery  and  enters  the  skull  through  the  jugular  fora- 
men. This  foramen  is  located  external  and  posterior  to  the  opening 
which  marks  the  commencement  of  the  carotid  canal.  Just  below 
the  base  of  the  skull  the  glosso-pharyngeal  nerve  passes  forward  be- 
tween the  internal  jugular  vein  and  the  internal  carotid  artery  and 
then  continues  forward,  below  the  stylo-glossus  muscle,  to  reach  the 
side  of  the  base  of  the  tongue.  Just  above  the  level  of  the  hyoid 
bone  the  hypoglossal  nerve  curves  forward  between  the  artery  and 
the  vein.  The  spinal  accessory,  at  the  base  of  the  skull,  is  situated 
between  the  internal  carotid  artery  and  the  internal  jugular  vein, 
but  passes  backward  and  outward  to  reach  the  deep  surface  of  the 
sterno-mastoid  muscle. 

The  External  Caeotid  Artery,  at  its  origin,  is  located  in  the 
superior  carotid  triangle  in  front  of  the  internal  carotid  artery.  It 
passes  upward  to  a  point  between  the  posterior  border  of  the  ramus 
of  the  jaw  and  the  mastoid  process,  and  here,  within  the  substance  of 
the  parotid  gland,  divides  into  the  temporal  and  internal  maxillary. 
As  it  ascends  upon  the  side  of  the  neck  it  describes  a  gentle  curve 
with  the  convexity  forward  and  is  placed  upon  a  plane  anterior  to  the 
internal  carotid,  giving  off  many  branches  to  the  muscles  and  struct- 
ures in  the  neck  and  to  the  tongue.  It  lies  in  front  of  the  anterior 
border  of  the  sterno-mastoid,  being  covered  only  by  the  skin, 
platysma,  and  deep  fascia;  higher  up,  on  a  level  with  the  angle  of 
the  lower  jaw,  it  is  covered  by  the  posterior  belly  of  the  digastric 
and  stylo-hyoid,  and  at  its  bifurcation  into  its  terminal  branches  it 
lies  deep  within  the  substance  of  the  parotid  gland. 

The  external  carotid  artery  does  not  lie  as  deep  in  the  neck  as 
the  internal  carotid;  upon  a  level  with  the  angle  of  the  lower  jaw 
the^e  two  vessels  are  separated  from  each  other  by  the  stylo-glossus 
and  stylo-pharyngeus  muscles  (together  with  the  glosso-pharyngeal 
nerve).  Both  these  muscles  arise  from  the  styloid  process  and  pass 
forward,  between  the  external  and  internal  carotid  arteries,  in  their 
course  to  reach  the  side  of  the  tongue  and  the  pharynx. 

As  the  external  carotid  artery  lies  within  the  parotid  gland  it 


SURGICAL  ANATOMY  OF  THE  NECK.  139 

is  crossed,  upon  a  level  with  the  lower  border  of  the  lobe  of  the  ear, 
by  the  divisions  of  the  facial  nerve.  The  temporo-maxillary  vein, 
which  is  formed  by  the  junction  of  the  temporal  and  internal  maxil- 
lary veins,  also  lies  superficial  to  it.  Below  the  angle  of  the  jaw 
the  artery  is  crossed  by  the  temporo-facial  vein;  this  vessel  is  formed 
by  the  facial  and  a  large  branch  from  the  temporo-maxillary,  and 
after  receiving  the  lingual  and  sometimes  the  superior  thyroid,  ter- 
minates in  the  internal  jugular. 

Below  the  level  of  the  hyoid  bone  the  external  carotid  gives  off 
the  superior  thyroid.  This  branch  passes  forward  and  downward  to 
the  lateral  lobe  of  the  thyroid  gland  and  gives  branches  to  the 
larynx.  The  next  branch  given  off  above  the  superior  thyroid  is  the 
lingual.  This  vessel  passes  forward,  beneath  the  digastric  and  stylo- 
hyoid muscles  and  beneath  the  hyo-glossus,  to  supply  the  tongue. 
The  next  branch  above  is  the  facial.  The  facial  is  directed  forward 
and  upward  and  curving  over  the  inferior  border  of  the  lower  jaw, 
in  the  groove  just  in  front  of  the  masseter  muscle,  ascends  upon 
"the  side  of  the  face,  nose,  etc.  At  its  origin  the  facial  artery  lies 
beneath  the  posterior  belly  of  the  digastric  and  stylo-hyoid  mus- 
cles close  to  the  posterior  border  of  the  submaxillary  gland,  which 
it  grooves'  and  supplies;  here  it  gives  off  its  submental  branch,  which 
runs  forward  upon  the  under  surface  of  the  mylo-hyoid  muscle 
dose  to  the  body  of  the  lower  jaw.  From  its  posterior  aspect,  upon 
-a  level  with  the  origin  of  the  facial,  the  external  carotid  artery  gives 
off  its  occipital  branch.  This  vessel  passes  upward  and  backward 
across  the  internal  jugular  vein  and  ascends  beneath  the  anterior 
border  of  the  sterno-mastoid  muscle  to  reach  the  occipital  region  of 
the  head.  Above  the  origin  of  the  occipital,  also  from  its  posterior 
aspect,  the  external  carotid  gives  off  the  posterior  auricular.  This 
vessel  courses  upward  and  backward,  running  close  behind  the  ear 
.and  supplying  this  and  the  mastoid  region.  The  hypoglossal  nerve 
swings  forward  across  the  outer  side  of  the  external  carotid  artery 
upon  a  level  with  the  origin  of  the  occipital. 

The  Inteenal  Jtjgulae  Vein  lies  close  to  the  outer  side  of 
~the  common  carotid  artery  and  its  continuation,  the  internal  ca- 
rotid. This  vessel  is  large,  as  big  around  as  the  little  finger,  very 
thin  walled,  and  lies  in  the  same  connective-tissue  bed  with  the 
artery  and  the  pneumogastric  nerve.  It  is  formed  above,  at  the 
base  of  the  skull,  by  the  union  of  the  lateral  (sigmoid)  and  inferior 
petrosal  sinuses.     These  vessels   emerge  from  the  interior  of  the 


140  NECK  AM)  TONGUE. 

skull  through  the  jugular  foramen,  "which  is  situated  behind  and 
external  to  the  conimeneenient  of  the  carotid  canal:  the  pnenmo- 
gasfaac,  spinal  accessory,  and  glosso-pharyngeal  nerves  also  emerge 
frori  the  iraninni  through  the  jugular  foramen.  Just  outside  the 
skull  the  lateral  and  the  inferior  petrosal  sinuses  join  and  form  a 
bulbous  dilatati  liich  marl:-  the  :  ommeneement  of  the  internal 

jugular  rein.  At  the  root  xf  the  neck  the  internal  jugular  termi- 
nates by  joining  with  the  subclavian  to  form  the  innominate.  Ir.  its 
course  through  the  neck  the  vein  receives  a  number  of  large 
branches:  the  temporo-faeial,  lingual,  and  superior  and  middle  thy- 
roids. A  chain  of  lymphatic  nodes  is  situated  along  the  outer  side 
of  the  vein,  close  to  its  -wall,  and  these  may  be  diseased  and  require 
extirpation.  On  the  right  side,  in  the  root  of  the  neck,  where  the 
internal  jugular  unites  with  the  subclavian,  the  right  lymphatic  duet 
is  seen  to  enter  the  vessel.  TTpon  the  left  side  of  the  neck  the 
thoracic  duet  enters  the  vein  at  its  junction  with  the  subclavian; 
the  thoracic  duet  arches  over  the  third  part  of  the  subclavian  artery 
and  across  the  front  of  the  :endon  of  the  scalenus  antieus  in  order 
to  reach  the  vein. 

Tee  Subclavian  Aeieet. — This  ssel  upon  the  right  side  is 
deri~ei  from  the  mnominate,  which  bifurcates  bellied  the  right 
sterno-clavicular  articulation  into  the  common  carotid  and  sub- 
clavian. The  left  sol  -  .iven  off  from  the  left  end  of  the 
transverse  irt  ::  the  arch  ::  the  aorta  and  ascends  in  the  upper 
part  of  the  ehest  as  far  as  the  left  -    .no-clavicular  articulation. 

From  the  sterno-clavicular  articulation,  upon  either  side,  the 
e  belavian  artery  arches  outward  across  the  root  if  the  neck  and 
passes  into  the  axilla  tc  become  the  axillary.  In  the  root  of  the 
neck  the  artery  is  found  in  the  subclavian  triangle  resting  directly 
upon  the  first  rib. 

The  tendon  of  the  scalenus  antieus,  at  its  attachment,  is  situated 
in  front  ::'  the  subclavian  artery,  and  thus,  for  purposes  of  descrip- 
tioL.  --el  into  three  parts.    The  first  part  of  the 

corresponds  to  that  portion  which  is  included  between  its 
■ .  .in  and  the  inner  margin  of  the  tendon  of  the  scalenus  ant:     - 
the  second  part  of  the  artery  corre-     ads  to  the  portion  immediately 
bind  the  tendon  of  the  8(   leu    s,  and  the  thn       art  of  the  artery 
reaches  from  the  on:  of  the  ten     n  of  the  scalenus  antieus 

tc  "lae  point  where  if  enters  the  axilla  to  become  the  axillary.  The 
first  and  second  parts  of  the  artery  are  in  intimate  relation  with  the 


SURGICAL  ANATOMY  OF  THE  NECK.  141 

apex  of  the  lung  and  dome  of  the  pleura;  the  third  portion  rests 
upon  the  upper  surface  of  the  first  rib.  The  trunks  of  the  brachial 
plexus  in  their  course  through  the  subclavian  triangle  are  situated 
above  the  subclavian  artery.  The  subclavian  artery  gives- off  several 
large  branches;  from  its  first  part  the  vertebral,  internal  mammary, 
and  thyroid  axis  (inferior  thyroid,  suprascapular,  transversalis  colli); 
from  the  second  part,  the  superior  intercostal.  The  origin  of  these 
branches  varies  in  different  individuals  and  in  the  same  individual 
upon  either  side. 

The  subclavian  vein  is  the  continuation  of  the  axillary.  It 
passes  inward  across  the  root  of  the  neck,  beneath  the  clavicle  and  in 
front  of  the  scalenus  anticus  tendon,  resting  upon  the  upper  surface 
of  the  first  rib  and  lying  in  front  and  to  the  inner  side  of  the  artery. 
It  is  situated  a  considerable  distance  away  from  the  artery,  from 
which  it  is  separated  by  the  tendon  of  the  scalenus  anticus.  The 
subclavian  vein  joins  with  the  internal  jugular  to  form  the  innomi- 
nate. Upon  the  right  side  where  these  two  veins  join  they  receive 
the  right  lymphatic  duct,  and  upon  the  left  side,  at  their  junction, 
they  receive  the  thoracic  duct. 

The  Ineeeioe  Thyeoid  Aeteey  is  seen  deep  in  the  lower  part 
of  the  inferior  carotid  triangle.  It  is  a  branch  of  the  thyroid  axis 
which  arises  from  the  first  part  of  the  subclavian,  and  curves  upward 
and  inward,  passing  inward,  behind  the  common  carotid  artery,  about 
the  level  of  the  transverse  process  of  the  sixth  cervical  vertebra  in 
order  to  reach  the  lower  part  of  the  thyroid  gland.  As  this  vessel 
passes  behind  the  common  carotid  artery,  etc.,  it  is  crossed  from 
above  downward  by  the  sympathetic  nerve.  This  nerve  usually 
descends  in  front  of  the  inferior  thyroid  artery,  but  sometimes  be- 
hind it.  Just  before  the  artery  reaches  the  thyroid  gland  it  is  crossed 
by  the  recurrent  laryngeal  nerve,  which  ascends  in  the  space  between 
the  trachea  and  the  oesophagus  to  reach  the  larynx. 

The  Veetebeal  Aeteey  lies  deep  in  the  lower  part  of  the 
neck.  It  arises  from  the  first  part  of  the  subclavian  between  the 
scalenus  anticus  muscle  in  front  and  the  longus  colli  behind  and 
enters  the  foramen  in  the  base  of  the  transverse  process  of  the  sixth 
cervical  vertebra.  The  prominent  tubercle  on  the  transverse  process 
of  this  vertebra  is  a  good  guide  to  the  artery.  The  artery  may  be 
reached  through  the  subclavian  triangle  by  drawing  the  sterno- 
mastoid  forward  toward  the  middle  line  or  by  nicking  or  incising  its 
posterior  border. 


142 


NECK  AND  TONGUE. 


OPERATIONS  UPON  THE  NECK. 

Tracheotomy  means  opening  into  the  air-passage  either  for 
relief  when  obstruction  exists  or  as  a  preliminary  step  to  other  op- 
erations; for  example,  extirpation  of  the  larynx,  amputation  of  the 
tongue,  etc. 

In  1869,  as  a  preliminary  to  excision  of  the  jaw,  ISTussbaum  per- 
formed a  tracheotomy  and  tamponed  the  pharynx  with  a  compress 
to  prevent  blood  from  entering  the  larynx  during  the  operation,  the 
anaesthetic  being  administered  through  the  tracheotomy  tube. 

Tampon  of  the  Trachea. — Trendelenburg  uses  a  tracheotomy 
tube  which  is  surrounded  by  a  thin,  balloon-like  structure  provided 
with  a  cannula  so  that  it  may  be  inflated  after  it  has  been  introduced 


Fig.  77.— Tracheotomy  Tube. 


Fig.  78.— Trendelenburg  Tampon  Can- 
nula. T,  tube  to  inflate  balloon.  Anaes- 
thetic is  given  through  a  long  tube  and 
funnel  attached  to  tracheotomy  tube. 


into  the  trachea,  in  this  way  plugging  the  trachea  and  preventing  the 
entrance  of  blood,  etc.  The  anaesthetic  is  administered  through  the 
tracheotomy  tube,  to  which  a  long  rubber  tube  provided  with  a  fun- 
nel is  attached;  in  the  bottom  of  the  funnel  there  is  a  wad  of  cotton 
upon  which  the  anaesthetic  is  dropped.  The  tracheotomy  tube  and 
tampon  may  be  allowed  to  remain  in  the  trachea  for  seven  or  eight 
days  after  the  operation. 

The  Site  of  Operation. — The  opening  into  the  air-passage 
may  be  made: — 

1.  JThrongh  the  trachea  above  the  isthmus  of  the  thyroid  gland 
(high  tracheotomy).  This  is  the  preferable  operation  and  usually 
includes,  in  addition,  division  of  the  cricoid  cartilage  (crico-trache- 
otomy). 


OPERATIONS  UPON  THE  NECK.  143. 

2.  Through  that  part  of  the  trachea  which  is  covered  by  the 
isthmus  of  the  thyroid  gland  (median  tracheotomy). 

3.  Through  the  trachea  below  the  isthmus  of  the  thyroid  gland 
(low  tracheotomy).  This  operation  is  rather  less  preferable,  because 
at  this  level  the  trachea  lies  deeper — farther  away  from  the  surface,, 
and,  besides,  one  may  meet  the  inferior  thyroid  veins  or  some  of 
their  branches  or  there  may  be  an  arteria  thyroidea  ima  present. 
This  is  the  site  usually  selected  for  a  preliminary  tracheotomy  in 
conjunction  with  operations  upon  the  larynx;  for  example,  extirpa- 
tion of  the  larynx. 

4.  Through  the  crico-thyroid  membrane.  This  is  really  a  laryn- 
gotomy,  but  it  is  well  to  include  it  with  the  tracheotomies. 

High  Tracheotomy  (Crico-tracheotomy). — This  is  the  op- 
eration usually  performed,  and  has  the  advantage  that  no  vessels- 
of  moment  are  met  with;  and  that  this  part  of  the  air-tube  is- 
located  quite  superficially,  near  the  surface. 

The  patient  lies  upon  the  back  with  the  shoulders  raised  and  the 
head  thrown  back.  If  the  symptoms  of  suffocation  are  urgent,  one 
may  dispense  with  an  anaesthetic  or  may  give  simply  a  few  whiffs 
of  chloroform.    The  operation  may  be  done  under  cocain  ansesthesia. 

By  palpation,  the  ring-like  cricoid  cartilage,  which  is  the  best 
landmark,  is  readily  located.  In  men  the  prominent  thyroid  carti- 
lage may  be  felt  and  seen  as  Adam's  apple,  but  in  women  and  chil- 
dren this  is  not  prominent  and  is  not,  therefore,  a  good  guide. 

An  incision  is  made  through  the  skin  and  subcutaneous  fat  from 
the  lower  border  of  the  thyroid  cartilage — just  above  the  cricoid — 
downward,  in  the  middle  line  of  the  neck,  for  a  distance  of  one  and 
one-half  inches.  In  making  this  skin  incision  some  small  tributaries 
of  the  anterior  jugular  vein  may  be  encountered;  to  these  clamps- 
are  applied  and  the  skin  retracted,  exposing  thus  the  deep  cervical 
fascia,  which  unites  the  edges  of  the  sterno-hyoid  muscles  of  either 
side  with  each  other.  This  layer  of  fascia  is  incised  along  the  middle 
line,  corresponding  to  the  incision  in  the  integument.  The  edges  of 
the  wound  being  now  retracted,  there  are  exposed,  above,  the  cricoid 
cartilage  and  just  below  the  cricoid,  lying  transversely  across  the 
front  of  the  trachea,  the  isthmus  of  the  thyroid  gland.  The  isthmus 
of  the  thyroid  gland  is  located  about  one-half  inch  below  the  cricoid 
cartilage,  to  which  it  is  connected  by  a  process  of  the  deep  cervical 
fascia.  This  slip  of  fascia  covers  or  conceals  the  upper  two  rings 
of  the  trachea;    so  that,  in  order  to  expose. these,  it  is  necessary  to> 


1-14  NECK  AND  TONGUE. 

pick  up  this  band  and  snip  it  transversely,  after  which  the  isthmus 
may  he  drawn  downward  and  the  upper  rings  of  the  trachea  exposed 
to  view. 

The  next  step  is  to  enter  the  air-passage,  but  before  doing  this 
all  bleeding  points  should  be  clamped.  At  times,  during  the  opera- 
tion, the  larynx  moves  violently  up  and  down  in  forced  efforts  at 
respiration,  and  in  order  to  steady  it  a  tenaculum  must  be  employed. 
This  is  introduced  into  the  larynx  above  the  cricoid  cartilage,  pierc- 
ing the  crico-thyroid  membrane,  and  hooks  the  cricoid  cartilage 
firmly  upon  its  posterior  aspect  a  little  to  the  right  of  the  middle 
line.  The  operator  holds  this  tenaculum  with  the  left  hand,  thus 
steadying  the  larynx  and  trachea,  and,  with  a  sharp-pointed  knife 
held  short  in  the  right  hand,  the  cricoid  and  one  or  two  upper  rings 
of  the  trachea  are  cut  deliberately  from  above  downward.  One 
guards  the  knife  blade  in  order  to  avoid  injuring  or  perforating  the 
posterior  wall  of  the  trachea.  Having  made  an  opening  in  the  air- 
tube  about  one-half  inch  long  and  still  retaining  the  tenaculum 
which  was  hooked  into  the  cricoid  to  the  right  of  the  middle  line, 
a  second  tenaculum  is  now  hooked  into  the  other  side  of  the  cricoid, 
to  the  left  of  the  middle  line,  and  the  incision  in  the  air-passage 
thus  held  open  while  the  tube  is  being  -introduced. 

Occasionally  the  thyroid  gland  has  a  well-marked  middle  lobe 
occupying  the  site  of  the  isthmus  and  ascending  upon  the  front  of 
the  cricoid.  This  extra  lobe  is  seldom  present,  but,  when  it  is,  it 
must  be  dislocated  downward  in  order  to  expose  the  cricoid  and  the 
upper  part  of  the  trachea.  Usually  it  is  not  necessary  to  apply  any 
ligatures,  as  the  cut  vessels  cease  bleeding  after  a  few  minutes'  ap- 
plication of  the  artery  forceps;  still,  if  any  spurting  vessels  are  met, 
they  should  be  ligated.  The  edges  of  the  skin  may  be  brought  to- 
gether with  two  interrupted  catgut  sutures,  one  above  and  the  other 
below  the  tube. 

The  tube  is  held  in  place  by  a  tape  tied  around  the  neck  and 
the  wound  dressed  with  gauze  packed  loosely  about  the  wound  and 
the  tube. 

Low  Tracheotomy.  —  The  opening  is  made  into  the  trachea 
below  the  isthmus  of  the  thyroid  gland.  This  is  not  usually  the  site 
of  choice,  although  it  is  at  times  indicated.  This  part  of  the  trachea 
lies  farther  away  from  the  surface,  deeper,  and  one  may  meet  the 
inferior  thyroid  veins,  which  descend  in  front  of  the  trachea,  al- 
though they  usually  lie  well  to  either  side  of  the  middle  line,  thus 


OPERATIONS  UPON  THE  NECK.  145 

leaving  the  line  of  incision  free.  At  times  there  is  an  arteria  thy- 
roidea  ima  ascending  in  front  of  this  part  of  the  trachea:  a  rather 
unusual  condition. 

The  incision,  in  the  middle  line  of  the  neck,  commences  above 
at  a  point  just  below  the  cricoid  cartilage,  and  is  continued  down- 
ward toward  the  sternum,  for  a  distance  of  one  and  one-half  to 
two  inches.  The  incision  penetrates  first  through  the  skin  and  fat, 
and  is  then  continued  deeper  through  the  deep  cervical  fascia,  ex- 
posing the  front  of  the  trachea.  After  the  trachea  has  been  exposed 
all  bleeding  points  must  be  clamped;  usually  the  hemorrhage  is  only 
venous  and  ceases  after  the  artery  forceps  have  been  applied  for  a 
few  minutes.  The  operator  is  now  ready  to  make  the  opening  in 
the  trachea,  which  should  be  placed  below  the  level  of  the  isthmus 
of  the  thyroid  gland;  the  isthmus  may  be  drawn  upward  toward 
the  cricoid  cartilage  in  order  to  give  more  room.  All  bleeding  should 
be  controlled  before  the  trachea  is  opened. 

Before  making  the  incision  in  the  trachea  a  tenaculum  is  intro- 
duced into  the  trachea,  just  below  the  isthmus  of  the  thyroid  gland 
and  a  little  to  one  side  of  the  middle  line,  to  steady  the  trachea,  and 
with  a  sharp-pointed  knife,  held  short  by  the  blade,  an  incision  is 
made  into  the  trachea  from  below  upward,  cutting  two  or  three 
rings.  Still  steadying  the  trachea  with  the  first  tenaculum,  a  second 
tenaculum  is  introduced  into  the  incision  in  the  trachea,  and  while 
it  is  thus  held  open  the  tube  is  introduced.  The  tenacula  are  not 
withdrawn  until  the  tube  is  in  the  trachea. 

Any  spurting  vessels  or  large  veins  may  be  ligated,  and  one  or 
two  stitches  may  be  taken  in  the  skin  wound.  The  left  innominate 
vein  is  not  in  danger  if,  in  incising  the  trachea,  the  knife  is  not 
carried  below  the  level  of  the  sternum. 

Median  Tkacheotomy. — The  opening  into  the  trachea  is  made 
beneath  the  isthmus  of  the  thyroid  gland,  which  is  divided  in  order 
to  expose  this  part  of  the  trachea.  This  operation  can  be  done 
rapidly. 

The  incision  passes  through  the  skin  and  fat  and  reaches  from 
the  cricoid  cartilage  downward,  in  the  middle  line  of  the  neck,  for 
a  distance  of  one  and  one-half  to  two  inches.  The  incision  is  then 
carried  deeper  through  the  deep  fascia,  between  the  edges  of  the 
sterno-hyoid  muscles,  when  the  isthmus  of  the  thyroid  gland  is  ex- 
posed. The  isthmus  is  divided  and  the  trachea  recognized.  In 
dividing  the  isthmus  we  cut  several  venous  branches,  which  bleed 


146  NECK  AND  TONGUE. 

and  must  be  clamped.  The  bleeding  should  be  controlled  before  the 
trachea  is  opened.  Bleeding  points  may  be  clamped  and  their  liga- 
tion postponed  until  after  the  tube  has  been  introduced  into  the 
trachea  if  time  is  limited.  The  trachea  is  steadied  with  a  tenaculum 
and  incised,  and  the  tube  introduced,  as  in  the  foregoing  operation. 

Transverse  Laryngotomy. — This  is  an  emergency  operation 
and  may  be  rapidly  performed.  One  may  open  the  windpipe,  after 
locating  the  cricoid  cartilage  and  using  this  as  a  guide,  by  cutting 
transversely  through  the  skin  and  crico-thyroid  membrane:  i.e., 
between  the  upper  border  of  the  cricoid  and  the  lower  border  of  the 
thyroid  cartilage.  There  is  some  probability  of  wounding  the  crico- 
thyroid artery,  a  small  branch,  yet  this  is  not  very  likely  as  the  in- 
cision is  made  transversely:    parallel  with  the  course  of  the  artery. 

Thyrotomy. — Division  of  the  thyroid  cartilage  may  be  either 
incomplete  or  complete. 

Incomplete  Thyrotomy. — The  incision  is  placed  in  the  middle 
line  of  the  neck  and  commences,  above,  at  a  point  just  below  the 
upper  border  of  the  thyroid  cartilage,  and  is  continued  downward 
to  a  point  just  below  the  cricoid  cartilage;  it  is  about  one  and  one- 
half  to  two  inches  long  and  reaches  through  the  skin  and  deep 
fascia,  exposing  the  cricoid  and  thyroid  cartilages.  The  edges  of  the 
wound  are  retracted  and  the  crico-thyroid  membrane  incised,  thus 
entering  the  larynx.  In  incising  the  crico-thyroid  membrane  the 
crico-thyroid  branches  may  be  cut;  these  are  small  branches,  but 
they  should  be  clamped  if  they  bleed,  as  even  a  small  quantity  of 
blood  sucked  into  the  wind-pipe  may  seriously  embarrass  respira- 
tion. We  then  proceed  to  enlarge  the  opening  into  the  larynx  by 
dividing  the  cricoid  cartilage  and  the  lower  part  of  the  thyroid 
cartilage,  to  an  extent  sufficient  to  permit  the  extraction  of  foreign 
bodies,  etc.  One  should  avoid,  if  possible,  incising  the  thyroid  carti- 
lage beyond  the  level  at  which  the  true  vocal  cords  are  attached. 

If  this  operation  is  done  for  the  removal  of  a  foreign  body,  one 
may  close  the  opening  in  the  larynx  and  omit  the  introduction  of  a 
tube;  still  it  is  probably  not  unwise  to  insert  the  tube  and  leave  it 
for  a  few  days  in  all  cases,  because,  as  a  result  of  the  operation,  there 
may  be  some  oedema  of  the  glottis  caused. 

Complete  Thyrotomy  consists  of  a  median  section  through  the 
thyroid  cartilage.  This  operation  is  done  for  the  purpose  of  ex- 
ploring the  interior  of  the  larynx  and  for  the  removal  of  foreign 
bodies,  growths,  etc. 


OPEEATIONS  UPON  THE  NECK.  147 

During  the  operation  the  trachea  must  be  kept  clear  of  blood. 
The  operation  should  be  performed  with  the  patient  in  the  Rose 
position  unless  a  tampon  cannula  is  used,  when  the  patient  may  be 
placed  in  the  usual  tracheotomy  position  with  the  shoulders  raised 
and  the  head  thrown  back.  The  tampon  cannula  may  be  introduced 
through  a  preliminary  high  tracheotomy,  done  at  the  same  sitting, 
previous  to  opening  the  larynx,  or  else  the  cannula  may  be  inserted 
through  the  incision  that  is  made  in  the  larynx  and  which  may  be 
prolonged  downward,  through  the  cricoid  and  upper  rings  of  the 
trachea  for  this  purpose.  Instead  of  a  high  tracheotomy,  a  prelimi- 
nary, low  tracheotomy  may  be  performed  and  the  tampon  cannula 
introduced  at  this  point. 

The  incision  is  placed  in  the  middle  line  of  the  neck,  reaching 
from  the  hyoid  bone,  above,  to  a  point  below  the  level  of  the  cricoid 
cartilage.  The  incision  extends  through  the  skin  and  deep  fascia 
and  exposes  the  thyroid  cartilage. 

The  next  step  is  to  open  the  larynx.  The  point  of  the  knife 
is  introduced  through  the  crico-thyroid  membrane  between  the 
cricoid  and  the  lower  border  of  the  thyroid  cartilage.  In  doing  this 
the  crico-thyroid  branch  may  be  cut  and  should  be  clamped  and  tied. 
Now,  with  a  curved  probe-pointed  knife,  which  is  introduced  into 
the  larynx  and  passed  upward  between  and  beyond  the  vocal  cords, 
the  thyroid  cartilage  is  split  into  its  two  halves  from  within  outward, 
in  the  middle  line,  throughout  its  entire  length  up  to  or  into  the 
thyro-hyoid  membrane.  The  thyroid  cartilage  may  also  be  divided 
from  without  inward.  At  times  the  thyroid  cartilage  is  ossified,  and 
a  strong  scissors  or  thin  saw  is  necessary  in  order  to  accomplish  its 
division. 

After  the  thyroid  cartilage  has  been  split  its  edges  are  held 
apart  with  sharp  retractors  or  tenacula,  and  the  interior  of  the 
larynx  may  then  be  freely  explored.  We  may,  in  addition,  divide  the 
cricoid  cartilage  and  the  upper  rings  of  the  trachea  if  this  has  not 
already  been  done  or  if  more  room  is  required  or  in  order  to  intro- 
duce a  tampon  cannula. 

In  cutting  into  the  thyro-hyoid  membrane  one  should  avoid  the 
superior  laryngeal  vessels  and  nerve,  which  pierce  this  membrane 
upon  either  side  to  enter  and  supply  the  larynx. 

It  may  not  be  necessary  to  suture  the  two  halves  of  the  thyroid 
cartilages,  as  these  often  adapt  themselves  very  well  without  suture, 
especially  if  the  cricoid  cartilage  has  not  been  divided.    It  is  probably 


148  NECK  AND  TONGUE. 

wise,  however,  in  all  cases,  to  introduce  two  or  three  chromicized 
catgut  sutures  through  the  perichondrium  to  hold  the  edges  of  the 
two  halves  of  the  thyroid  cartilage  in  contact  or  one  silver  wire  suture 
may  he  passed  through  each  edge  of  the  cartilage.  The  incision 
in  the  skin  may  be  partly  closed  with  catgut  sutures. 

The  tampon  cannula,  if  used,  may  be  left  in  place  for  a  few 
clays  if  it  is  well  borne,  as  it  prevents  the  entrance  of  blood  and  dis- 
charge into  the  trachea  and  lungs. 

Laryngectomy  (Extirpation  of  the  Larynx).  —  This  operation 
should  be  preceded  by  a  low  tracheotomy,  which  may  be  done  a 
week  or  more  in  advance  of  the  major  operation  in  order  to  accustom 
the  patient  to  the  presence  of  the  tube  and  to  bring  about  fixation 
of  the  trachea  to  the  skin,  etc.,  of  the  neck. 

If  the  preliminary  tracheotomy  has  not  been  done,  one  should 
operate  with  the  patient  in  the  Eose  position,  or,  if  the  operation 
is  done  with  the  patient  in  the  customary  tracheotomy  position,  it 
will  be  necessary,  as  soon  as  the  larynx  has  been  isolated  and  all  the 
vessels  that  supply  it  ligated,  to  cut  the  larynx  away  from  the  trachea 
below  and  then,  at  once,  introduce  the  tampon  cannula  into  the 
upper  end  of  the  trachea.  The  preliminary  tracheotomy,  with  the 
introduction  of  the  tampon  cannula,  is  probably  the  most  preferable 
plan.  The  incision  is  made  in  the  middle  line  from  the  hyoid  bone  to 
a  point  below  the  cricoid  cartilage;  to  this  incision  a  second  trans- 
verse incision  may  be  added  which  extends  outward,  parallel  with 
the  hyoid  bone,  between  the  hyoid  bone  and  upper  border  of  the 
thyroid  cartilage,  as  far  as  the  anterior  border  of  the  sterno-mastoid 
muscle,  thus  making  a  T-shaped  incision.  This  latter  supplementary 
incision  is  especially  advantageous  if  the  lymphatic  glands,  etc.,  are 
involved  in  the  pathological  process. 

The  incision  extends  through  the  skin  and  subcutaneous  fat  and 
deep  cervical  fascia,  and  exposes  the  thyroid  cartilage. 

The  edges  of  the  sterno-hyoid  muscles  are  next  recognized  and 
the  muscle  of  either  side  divided  transversely  either  partially  or 
completely.  The  parts  being  now  retracted,  we  expose  the  sterno- 
thyroid and  thyro-hyoid  muscles,  which  are  attached  upon  either 
side  of  the  thyroid  cartilage,  the  lateral  lobes  of  the  thyroid  gland 
being  situated  beneath  the  sterno-thyroid  muscles. 

We  now  begin  the  isolation  of  the  larynx,  separating  all  the 
soft  parts  either  with  an  elevator  or  with  the  knife,  the  edge  of  the 
instrument  working  close  to  the  surface  of  the  thyroid  cartilage.    If 


OPERATIONS  UPON  THE  NECK.  149 

we  use  the  elevator,  this  is  pushed  under  the  thyrohyoid  muscle, 
between  it  and  the  thyroid  cartilage,  and  the  attachment  of  this 
muscle  separated  from  the  side  of  the  thyroid  cartilage,  separating 
the  attachment  of  the  sterno-thyroid  at  the  same  time;  this  separa- 
tion may  be  accomplished  in  part  with  the  knife.  These  two  mus- 
cles are  really  one  and  the  same  continuous  muscle;  so  that,  after 
they  have  been  detached  from  the  thyroid  cartilage,  they  hang 
together  as  one  continuous  flat  band.  Instead  of  detaching  these 
muscles  as  described  they  may  be  simply  cut  away  from  the  sides 
of  the  thyroid  cartilages  with  the  knife.  The  soft  parts  are  now 
retracted  and  a  tenaculum  is  hooked  into  the  side  of  the  thyroid 
cartilage,  and  with  this  the  larynx  is  drawn  forward  and  to  one  side, 
so  that  we  are  enabled  to  reach  the  superior  laryngeal  artery  and  its 
accompanying  nervous  branch,  as  they  pierce  the  side  of  the  thyro- 
hyoid membrane  to  enter  the  larynx;  the  vessel  is  tied  double  and 
cut.  The  lateral  lobe  of  the  thyroid  gland,  which  lies  upon  the  side 
of  the  larynx  (in  the  natural  relation  of  the  parts  being  covered  by 
the  sterno-thyroid  muscle),  is  readily  separated  from  the  side  of  the 
larynx  with  the  elevator  or  the  finger.  At  this  stage  of  the  opera- 
tion the  superior  thyroid  artery,  which  ramifies  upon  the  upper  front 
surface  of  the  thyroid  gland,  is  usually  met  with.  This  vessel  need 
not  be  cut.  The  thyroid  isthmus  is  also  liberated  from  its  attach- 
ment to  the  cricoid  cartilage  and  pushed  downward  out  of  the  way. 

The  crico-thyroid  branch  of  the  superior  thyroid,  which  runs 
forward  and  inward  transversely  across  the  crico-thyroid  membrane, 
may  be  cut  and  should  be  clamped  and  tied.  There  is  also  an  in- 
ferior laryngeal  branch,  from  the  inferior  thyroid,  which  accom- 
panies the  inferior  laryngeal  nerve  into  the  larynx;  it  enters  the 
lower  back  part  of  the  larynx,  behind  the  articulation  between  the 
cricoid  and  thyroid  cartilages,  beneath  the  lateral  lobe  of  the  thy- 
roid gland;  this  branch  may  be  cut  and  should  be  tied.  The  small 
transverse  branch,  from  the  superior  thyroid,  which  runs  transversely 
inward  across  the  thyro-hyoid  membrane,  below  the  hyoid  bone,  to 
anastomose  with  its  fellow  of  the  opposite  side,  is  also  cut  and  tied. 

The  larynx  is  now  drawn  to  the  other  side,  and  while  the  soft 
parts  are  retracted  the  above  described  procedures  are  repeated  upon 
this  side. 

The  isolation  of  the  larynx  is  continued.  The  soft  parts  are 
strongly  retracted  to  one  side  and  with  a  sharp  hook  or  vulsella  the 
larynx  is  drawn  to  the  opposite  side;   then,  with  the  knife,  the  in- 


150  NECK  AND  TONGUE. 

ferior  constrictor  of  the  pharynx  is  separated  from  the  side  of  the 
thyroid  cartilage.  This  muscle  is  attached  upon  the  side  of  the 
thyroid  cartilage  close  to  its  posterior  border,  which  may  be  readily 
felt  by  the  fingers  in  the  wound.  This  muscle  is  separated  from  the 
cricoid  cartilage  also.  Care  should  be  exercised  to  work  close  to  the 
surface  of  the  cartilage  in  separating  this  muscle  so  as  to  avoid 
opening  into  the  pharynx,  and  also  to  avoid  division  again  of  the 
vessels  that  have  already  been  divided  and  tied.  The  parts  are  then 
separated  in  a  similar  manner  upon  the  other  side  of  the  larynx. 

We  are  now  ready  for  the  final  step  of  this  part  of  the  operation: 
the  separation  of  the  larynx  from  the  hyoid  bone  above,  from  the 
anterior  wall  of  the  pharynx  behind,  and  from  the  trachea  below. 

The  knife  is  introduced  through  the  thyro-hyoid  membrane  be- 
tween the  thyroid  cartilage  and  the  hyoid  bone,  and  this  membrane 
is  cut  in  a  direction  outward  and  backward,  at  the  same  time  draw- 
ing the  side  of  the  larynx  forward  with  a  sharp  hook  or  vulsella. 
In  performing  this  step  of  the  operation  one  should  avoid  again  cut- 
ting the  superior  laryngeal  artery  upon  the  proximal  side  of  its 
ligature  if  it  has  already  been  divided  and  tied.  The  other  half  of 
the  thyro-hyoid  membrane  is  then  cut  in  a  similar  manner.  If  it 
is  desired  to  excise  the  epiglottis  also,  and  this  is  usually  wise,  a 
probe-pointed  knife  may  be  introduced  through  the  incision  in  the 
thyro-hyoid  membrane,  between  the  upper  border  of  thyroid  cartilage 
and  the  hyoid  bone,  in  a  direction  upward  and  backward;  so  that, 
as  the  cut  is  made,  the  blade  of  the  knife  passes  between  the  base 
of  the  tongue  and  the  epiglottis.  The  finger  in  the  mouth  may 
serve  to  guide  the  knife.  If  the  epiglottis  is  to  be  left,  we  cut  di- 
rectly backward  between  the  upper  border  of  the  thyroid  cartilage 
and  the  hyoid  bone,  thus  leaving  the  epiglottis  attached  to  the  poste- 
rior aspect  of  the  hyoid  bone  and  to  the  root  of  the  tongue.  The 
front  of  the  larynx  is  now  seized  with  a  sharp  hook  or  vulsella  forceps 
and  drawn  directly  forward;  so  that  its  posterior  wall,  composed  of 
the  broad  posterior  part  of  the  cricoid  cartilage,  may  be  separated 
from  the  anterior  wall  of  the  pharynx;  the  anterior  wall  of  the 
pharynx  is  very  thin,  consisting  practically  only  of  a  layer  of  mu- 
cous membrane.  If  the  growth  involves  the  anterior  wall  of  the 
pharynx,  this  part  may  be  excised  together  with  the  larynx.  If  the 
pharynx  is  not  involved  in  the  disease,  the  separation  of  the  larynx 
from  the  pharynx  is  not  difficult. 

After  the  separation  of  the  larynx  from  the  pharynx  has  been 


OPERATIONS  UPON  THE  NECK.  151 

completed  to  a  point  below  the  level  of  the  cricoid  cartilage,  the 
larynx  is  cut  away  from  the  trachea,  from  behind  forward,  below 
the  level  of  the  cricoid  cartilage.  In  thus  severing  the  larynx  from 
the  trachea  the  inferior  laryngeal  arteries  and  nerves  are  cut,  and, 
if  the  vessels  have  not  already  been  tied,  they  should  be  secured  as 
they  spurt.     Thus  the  extirpation  is  complete. 

Instead  of  operating  as  described  above,  we  may,  after  freeing 
the  larynx  upon  the  sides,  etc.,  complete  the  operation  by  cutting 
the  larynx  away  from  the  trachea  below  the  level  of  the  cricoid 
cartilage,  packing  the  stump  of  the  trachea  at  once  with  a  pad  to 
prevent  the  entrance  of  blood  (a  preliminary  tracheotomy  having 
been  done);  and  then,  drawing  the  larynx  forward  with  a  sharp  hook 
or  vulsella,  this  is  separated  from  the  anterior  wall  of  the  pharynx 
from  below  upward;  and,  as  the  final  step  of  the  operation,  the 
larynx  is  cut  away  from  its  attachment  to  the  hyoid  bone  by  carry- 
ing the  knife  through  the  thyro-hyoid  membrane. 

The  superior  laryngeal  arteries,  that  enter  the  larynx  upon  the 
sides,  are  best  secured  before  beginning  the  actual  isolation  of  the 
larynx,  but  they  may  be  again  divided  accidentally  during  the  final 
steps  of  the  operation,  and  in  this  case  should  be  again  clamped  and 
tied;  other  vessels  may  be  secured  as  they  are  encountered  during 
the  course  of  the  operation.  The  wound  is  best  left  open.  If  the 
accessory  lateral  skin  incisions  have  been  made,  and  the  sterno- 
mastoids  have  been  divided,  these  parts  may  be  brought  together 
with  sutures.  The  opening  in  the  pharynx  especially,  if  it  has  been 
necessary  to  remove  a  considerable  part  of  its  wall,  may  be  closed  in 
part  by  interrupted  silk  sutures  with  their  ends  left  long  to  facilitate 
their  removal  later. 

One  should  arrange  good  drainage,  with  the  head  low,  so  as  to 
avoid  the  entrance  of  wound  secretions  into  the  trachea.  It  is  well 
to  leave  the  tampon  cannula  in  the  trachea  for  a  few  days  if  it  has 
been  used  during  the  operation.  The  wound  should  be  properly 
packed  and  the  dressings  changed  at  rather  frequent  intervals. 

Feeding  is  carried  on  through  a  tube  introduced  into  the  stom- 
ach either  through  the  mouth  or  through  the  wound  in  the  pharynx. 
If  a  tracheotomy  has  not  preceded  the  laryngectomy  by  a  week  or 
more,  the  stump  of  the  trachea  should  be  sutured  to  the  skin  in  order 
to  prevent  too  great  retraction  of  the  trachea.  In  cases  where  the 
disease  has  not  spread  beyond  the  larynx,  the  operation  is  compara- 
tively easy  and  not  accompanied  by  much  hemorrhage. 


152  NECK  AND  TONGUE. 

Before  proceeding  with  the  radical  operation  the  larynx  may 
be  split  in  the  middle  line  for  the  purpose  of  exploration.  It  may 
be  that  in  some  early  cases  the  removal  of  one-half  of  the  larynx 
will  suffice. 

Extirpation  of  Half  of  the  Larynx. — This  operation  is  analogous 
to  the  preceding.  The  larynx  is  first  split  in  the  middle  line  without 
injuring  the  vocal  cords. 

It  is  a  less  difficult  and  dangerous  operation,  and  recurrence 
is  no  more  frequent  after  this  less  radical  operation,  if  the  disease 
is  limited  to  one  side  of  the  larynx,  than  after  complete  extirpation. 
The  function  is  good  after  the  partial  operation. 

External  (Esophagotomy. — This  operation  is  usually  done  for 
the  removal  of  a  foreign  body  impacted  in  the  oesophagus. 

The  patient  lies  upon  the  back,  with  the  shoulders  raised  and 
the  head  thrown  back  and  over  toward  the  right  side. 

A  soft  rubber  tube  is  introduced  into  the  oesophagus  as  far  as 
it  will  go  to  serve  as  a  guide.  The  oesophagus  is  approached  through 
an  incision  in  the  left  side  of  the  neck. 

The  incision  is  made  about  three  inches  long,  corresponding  to 
the  anterior  border  of  the  sterno-mastoid  muscle,  the  midpoint  of 
the  incision  being  upon  a  level  with  the  cricoid  cartilage;  it  is  car- 
ried through  the  skin  and  subcutaneous  fatty  layer,  including  the 
platysma,  and  exposes  the  anterior  edge  of  the  sterno-mastoid  mus- 
cle. The  sterno-mastoid  is  then  drawn  aside  and  the  underlying 
layer  of  deep  cervical  fascia  is  incised,  when  the  internal  jugular 
vein  and  the  common  carotid  artery,  lying  in  their  connective-tissue 
sheath  and  crossed  by  the  anterior  belly  of  the  omo-hyoid  muscle, 
are  exposed.  These  vessels  are  drawn  outward  with  a  blunt  re- 
tractor. The  lateral  lobe  of  the  thyroid  gland,  partly  covered  by  the 
sterno-hyoid  and  sterno-thyroid  muscles,  is  then  recognized.  These 
structures  are  drawn  toward  the  middle  line  with  a  blunt  retractor. 
The  trachea,  which  may  now  be  readily  felt  with  the  fingers,  is  a 
guide  to  the  oesophagus,  the  oesophagus  being  located  posterior  to 
the  trachea  and  protruding  well  beyond  its  left  border.  The  tube 
in  the  oesophagus  assists  in  locating  it,  and  the  foreign  body,  if 
present,  may  also  be  felt.  The  middle  thyroid  vein,  as  it  passes 
outward  from  the  thyroid  gland  to  enter  the  internal  jugular,  may 
be  met  with,  and,  if  it  is  in  the  way,  may  be  cut  and  tied.  The 
inferior  thyroid  vein  may  also  be  seen. 

The  oesophagus  is  entered  in  the  inferior  carotid  triangle, — i.e., 


OPERATIONS  UPON  THE  NECK.  153 

below  the  omohyoid, — and,  if  necessary,  this  muscle  may  be  drawn 
to  one  side  or  divided.  The  recurrent  laryngeal  nerve,  as  it  ascends 
to  enter  the  larynx,  lies  in  front  of  the  oesophagus,  in  the  space 
between  the  trachea  in  front  and  the  oesophagus  behind,  and  should 
be  avoided  in  incising  the  oesophagus.  The  nerve,  during  the  opera- 
tion, is  not  encountered,  and  may  be  avoided  by  making  the  opening 
in  the  oesophagus  well  upon  the  side  and  thus  keeping  away  from 
the  front  of  the  tube. 

The  wall  of  the  oesophagus  is  picked  up  with  two  mouse-toothed 
forceps,  and  an  incision  made  corresponding  to  its  long  axis  and  of 
sufficient  length  to  permit  the  extraction  of  the  foreign  body  or  any 
other  necessary  manipulation. 

In  incising  the  oesophagus  one  should  make  a  clean  cut  in  order 
to  avoid  getting  between  the  layers  of  the  wall  of  the  tube,  which 
may  readily  happen  owing  to  the  looseness  of  the  tissue  between 
its  muscular  and  mucous  coats.  Some  oesophageal  branches  of  the 
inferior  thyroid  may  be  divided  in  making  the  opening  in  the  wall 
of  the  oesophagus  and  these  must  be  clamped  and  ligated. 

The  wound  in  the  wall  of  the  oesophagus  may  be  closed  with 
several  interrupted  sutures  of  silk  or  chromicized  catgut,  but  the 
external  wound  in  the  neck,  leading  down  to  the  incision  in  the 
oesophagus,  should  be  packed  and  left  unsutured. 

If  the  object  of  the  operation  is  to  establish  a  permanent  fistula 
(cesophagostomy),  the  edges  of  the  incision  in  the  oesophagus,  includ- 
ing its  mucous  and  muscular  coats,  may  be  fixed  to  the  edges  of  the 
skin  incision  with  several  interrupted  silk  stitches. 

Ligation  of  Blood-vessels.  The  Common  Cakotid  Artery. — 
The  common  carotid  may  be  tied  either  above  or  below  the  point 
where  the  omo-hyoid  crosses  it,  which  is  upon  a  level  with  the  cricoid 
cartilage.  It  is  ligated  preferably  and  more  readily  in  the  so-called 
superior  carotid  triangle:    above  the  crossing  of  the  omo-hyoid. 

The  linear  guide  to  the  common  carotid  is  a  line  drawn  from 
a  point  midway  between  the  angle  of  the  jaw  and  the  mastoid  process 
to  the  sterno-clavicular  articulation.  The  muscular  guide  is  the 
anterior  border  of  the  sterno-mastoid  muscle. 

The  incision  is  made  about  two  inches  long,  corresponding  to 
the  anterior  border  of  the  sterno-mastoid,  its  midpoint  upon  a  level 
with  the  cricoid  cartilage.  This  incision  penetrates  through  the 
skin  and  subcutaneous  fatty  layer,  including  the  platysma,  and 
should  expose  the  anterior  border  of  the  sterno-mastoid  muscle. 


154 


NECK  AND  TONGUE. 


The  edge  of  the  sterno-mastoid  should  be  recognized  and  drawn 
outward,  and  then,  after  carefully  incising  the  underlying  layer  of 
deep  cervical  fascia, — the  fascia  that  separates  the  vessels  from  the 
sterno-mastoid  muscle, — the  vessels,  surrounded  by  some  loose  con- 
nective tissue,  are  exposed — first,  the  internal  jugular  vein,  big  and 
thin-walled,  lying  to  the  outer  side  of  the  artery,  and  then  the  com- 
mon carotid,  whose  pulsation  is  readily  felt  and  seen  and  which  lies 
to  the  inner  side  of  the  vein.     The  pneumogastric  nerve,  which  is 


Fig.  79. — A,  incision  for  removal  of  lower  jaw;  B,  incision  for  ligation  of 
lingual  artery  and  Kocher's  amputation  of  tongue;  C,  incision  for  ligation  of 
common  carotid  and  for  cesophagotomy. 


located  between  the  artery  and  vein,  but  behind  them,  is  not  seen. 
The  anterior  belly  of  the  omo-hyoid  is  seen  as  it  crosses  the  vessels 
opposite  the  cricoid  cartilage.  The  loop  formed  by  the  descendens 
and  communicans  noni  may  also  be  recognized  upon  the  front  of 
the  vessels.  The  superior  thyroid  vein  crosses  the  artery  from 
within  outward  above  the  omo-hyoid  muscle,  and  the  middle  thyroid 
vein  below  this  muscle.  If  these  vessels  are  cut,  they  should  be 
clamped  and  tied. 

The  connective-tissue  sheath  which  incloses  the  artery  should 


OPERATION'S  UPON  THE  NECK.  155 

be  picked  up  with  mouse-tooth  forceps,  and  nicked  with  the  point 
of  the  knife  _  in  the  direction  of  the  long  axis  of  the  vessel;  into 
the  opening  thus  made,  a  director  is  introduced,  and,  working  close 
to  its  wall,  the  vessel  is  separated  all  around,  taking  care  to  avoid 
the  pneumogastrie  nerve,  which  lies  posteriorly.  A  blunt-pointed 
aneurism  needle  is  then  introduced  into  the  opening  and  carried 
around  the  artery  from  without  inward,  entering  between  the  artery 
and  the  vein.  The  ligature  is  then  drawn  around  the  vessel,  and 
we  are  ready  to  tie.  The  ligature  should  be  of  ordinary  catgut  and 
tied  with  a  square  knot.  After  the  ligature  is  in  place  and  before 
it  is  tied  the  parts  should  be  again  inspected  in  order  to  make  sure 
that  the  nerve  is  not  included.  Some  surgeons  tie  the  artery  double 
and  divide  it  between  the  ligatures,  but  this  is  probably  unnecessary. 
The  incision  is  closed  with  a  catgut  suture. 

The  Exteexal  Caeotid. — The  ligation  of  the  external  carotid 
is  practiced  as  a  preliminary  to  many  bloody  operations  about  the 
mouth,  jaws,  etc.,  and  to  control  hemorrhage  from  parts  supplied  by 
its  branches  when  the  branches  themselves  are  not  accessible.  The 
linear  guide  to  the  artery  is  the  same  as  that  for  the  common  carotid; 
the  muscular  guide  is  the  anterior  edge  of  the  sterno-mastoid.  At 
the  upper  border  of  the  thyroid  cartilage  the  common  carotid  artery 
bifurcates  into  the  external  and  internal  carotids,  and  it  is  close  to  its 
origin,  near  the  upper  border  of  the  thyroid  cartilage,  that  the  ex- 
ternal carotid  is  ligated.  The  incision  commences  at  the  level  of  the 
hyoid  bone  and  is  carried  downward,  for  a  distance  of  about  two 
inches,  along  the  anterior  border  of  the  sterno-mastoid.  The  in- 
cision penetrates  through  the  skin,  fat,  and  platysma  muscle  down 
to  the  deep  cervical  fascia,  exposing  the  edge  of  the  sterno-mastoid 
muscle,  which  should  be  recognized.  The  edges  of  the  incision  are 
drawn  apart  with  blunt-pronged  retractors  and  the  deep  cervical 
fascia  is  then  incised. 

The  pulsation  of  the  artery,  within  its  connective-tissue  sheath, 
may  now  be  both  seen  and  felt.  The  external  carotid  artery  lies  a 
little  in  front  of  the  anterior  edge  of  the  sterno-mastoid.  The  in- 
ternal carotid,  together  with  the  internal  jugular  vein  and  pneumo- 
gastrie nerve,  lies  posterior  to  the  external  carotid,  beneath  the 
anterior  edge  of  the  sterno-mastoid.  Corresponding  to  the  upper 
border  of  the  thyroid  cartilage,  the  loose  connective  tissue  that  in- 
vests the  artery  is  picked  up  with  a  thumb  forceps  and  snipped  with 
the  point  of  the  knife,  cutting  in  a  direction  corresponding  to  the  long 


156  NECK  AND  TONGUE. 

axis  of  the  vessel;  into  the  opening  which  is  thus  made  a  blunt 
director  is  introduced  and  worked  around  the  vessel,  sticking  close 
to  its  wall.  Through  the  path  thus  made  by  the  director  a  ligature 
is  carried  around  the  vessel  in  the  eye  of  an  aneurism  needle.  The 
ligature  is  then  tied  and  the  incision  closed.  After  the  ligature  has 
been  carried  around  the  artery  it  may  be  left  untied,  with  its  ends 
hanging  out  of  the  incision,  to  be  tied  only  in  case  an  emergency 
arises  calling  for  its  use. 

The  Internal  Carotid. — The  ligation  of  the  internal  carotid 
is  but  seldom  called  for.  The  internal  carotid  may  be  tied  through 
an  incision  similar  to  that  for  ligation  of  the  external  carotid.  The 
vessel  is  found  underneath  the  anterior  edge  of  the  sterno-mastoid, 
which  is  the  muscular  guide  to  it.  The  internal  carotid  has  the 
same  relations  to  the  internal  jugular  vein  and  pneumogastric  nerve 
that  the  common  carotid  has,  the  internal  carotid  being  really  the 
continuation  of  the  common;  and  these  structures  must  be  avoided 
in  isolating  the  vessel  and  passing  the  ligature. 

The  Subclavian  Artery. — The  third  part  of  the  subclavian 
artery  is  tied  after  it  is  exposed  in  the  subclavian  triangle. 

The  patient  is  placed  with  the  shoulders  somewhat  raised  and 
the  head  thrown  back  and  turned  toward  the  opposite  side,  the  arm 
being  drawn  down  to  depress  the  shoulder.  The  incision  corresponds 
to  the  middle  third  of  the  clavicle.  It  is  placed  just  above  the 
clavicle,  and  extends  from  the  anterior  border  of  the  trapezius  for- 
ward and  inward  almost  as  far  as  the  outer  border  of  the  sterno- 
mastoid  muscle;  the  incision  falls  a  little  short  of  the  edge  of  the 
sterno-mastoid  muscle  in  order  to  avoid  the  external  jugular  vein. 
The  incision  in  the  skin  may  be  made  by  drawing  the  integument  of 
the  neck  downward  over  the  surface  of  the  clavicle  and  then  cutting 
through  it,  down  upon  the  surface  of  the  clavicle;  when  the  skin 
is  released,  the  incision  is  found  to  lie  just  above  and  parallel 
with  the  clavicle.  This  incision  reaches  through  the  skin,  fat,  and 
platysma  down  to  the  deep  fascia.  The  deep  fascia,  which  reaches 
from  the  edge  of  the  trapezius  muscle  behind  to  the  sterno-mastoid 
in  front,  is  now  incised,  avoiding  the  external  jugular  vein,  which 
pierces  the  deep  cervical  fascia  behind  the  outer  edge  of  the  sterno- 
mastoid  muscle.  Beneath  the  deep  fascia  the  venous  plexus,  formed 
by  the  transversalis  colli  and  suprascapular,  is  encountered.  These 
veins  may  be  wounded,  but  are  readily  clamped;  often,  however, 
they  can  be  avoided  as  the  knife  may  be  discarded  after  the  deep 


OPERATIONS  UPON  THE  NECK.  157 

fascia  has  been  incised.  Beneath  the  deep  fascia  there  is  also  a  con- 
siderable quantity  of  loose  fat  and  connective  and  lymphatic  tissue. 

The  posterior  belly  of  the  omo-hyoid  muscle,  which  lies  pretty 
low  down  near  the  clavicle,  is  now  sought  and  must  be  drawn  upward 
to  show  the  subclavian  triangle,  of  which  it  forms  the  upper  bound- 
ary, the  anterior  boundary  being  formed  by  the  sterno-mastoid  and 
the  inferior  boundary  by  the  clavicle. 

"Within  the  triangle,  passing  transversely  outward,  are  the  trans- 
versalis  colli  and  suprascapular  arteries.  These  vessels  should  be 
avoided.  The  tendon  of  the  scalenus  anticus,  which  is  the  guide  to 
the  subclavian  artery,  may  be  felt  as  a  tense  cord  passing  straight 
up  and  down  beneath  the  posterior  or  outer  border  of  the  sterno- 
mastoid  and  attached  below  to  the  first  rib.  If  this  tendon  is  fol- 
lowed downward  as  far  as  its  attachment  to  the  first  rib,  one  may 
locate  the  subclavian  artery  as  it  passes  outward  and  forward  from 
behind  the  tendon  of  the  scalenus  anticus  muscle,  resting  directly 
upon  the  upper  surface  of  the  first  rib.  That  part  of  the  subclavian 
artery  which  lies  upon  the  first  rib  is  the  part  which  is  ligated.  The 
subclavian  vein  lies  a  considerable  distance  to  the  inner  side  of  and 
anterior  to  the  artery,  the  tendon  of  the  scalenus  anticus  interven- 
ing between  them,  and  is  not  apt  to  be  encountered  during  the  op- 
eration. "Within  the  triangle,  above  the  subclavian  artery,  may  be 
seen  the  three  cords  of  the  brachial  plexus.  These  pass  obliquely 
downward  and  outward  from  behind  the  scalenus  anticus  muscle,  and 
should  not  be  mistaken  for  the  artery,  which  is  the  lowest  structure 
in  this  triangle  and  rests  directly  upon  the  upper  surface  of  the  first 
rib.  These  structures  may  all  be  exposed  by  blunt  dissection,  sepa- 
rating with  the  finger  or  handle  of  the  knife,  after  the  deep  fascia 
has  been  incised. 

With  blunt  retractors  the  wound  is  held  open  and  the  con- 
nective-tissue sheath,  which  envelops  the  artery,  picked  up  and 
snipped  with  the  scissors  and  the  artery  then  separated  from  the 
adjoining  structures  with  a  blunt  director,  working  around  the  artery 
close  to  its  wall.  The  aneurism  needle  is  passed  around  the  artery 
from  without  inward,  avoiding  the  cords  of  the  brachial  plexus.  The 
subclavian  vein,  which  lies  below  and  internal  to  the  artery,  is  not 
apt  to  be  in  the  way. 

It  should  also  be  remembered  that  the  dome  of  the  pleura 
reaches  above  the  clavicle  into  the  subclavian  triangle,  and  that 
the  subclavian  artery  (second  part),  as  it  lies  behind  the  tendon  of 


158  NECK  AND  TONGUE. 

the  scalenus  anticus,  rests  upon  the  pleura,  and  care  should  be  taken 
to  avoid  injuring  this  structure,  especially  in  making  way  for  the 
passage  of  the  ligature. 

The  ligature  is  tied  with  a  square  knot,  deep  in  the  wound, 
without  lifting  the  artery  too  much  out  of  its  bed. 

The  Lingual  Aeteky. — This  operation  is  usually  performed 
in  combination  with  Kocher's  amputation  of  the  tongue.  The 
lingual  is  a  vessel  of  considerable  size,  that  of  each  side  supplying 
the  corresponding  half  of  the  tongue.  In  order  to  prevent  the 
entrance  of  blood  into  the  larynx  during  the  amputation  of  the 
tongue,  the  patient  is  placed  in  the  Eose  position,  or,  if  a  preliminary 
tracheotomy  has  been  done  and  a  Trendelenburg  tampon  cannula 
introduced,  or  if  an  ordinary  tracheotomy  tube  has  been  introduced 
and  the  pharynx  tamponed,  one  may  operate  with  the  patient  in  the 
ordinary  position,  the  shoulders  somewhat  raised,  and  the  head 
thrown  back  and  over  toward  the  opposite  side. 

An  incision  is  made  which  corresponds  to  the  boundaries  of  the 
submaxillary  triangle.  It  commences  in  front,  at  the  symphysis 
mentis,  and  is  carried  down  to  the  hyoid  bone,  thence  backward 
above  and  parallel  with  the  greater  horn  of  the  hyoid  bone  and  then 
in  a  direction  upward  and  backward  toward  the  mastoid  process  as 
far  as  the  angle  of  the  lower  jaw  (see  Fig.  79). 

This  incision  penetrates  through  the  skin,  fat,  and  platysma, 
down  to  the  deep  fascia.  The  apex  of  the  flap,  which  is  thus  marked 
out,  is  seized  with  the  fingers  and  reflected  upward  upon  the  side 
of  the  face  as  far  as  the  lower  border  of  the  jaw-bone.  In  reflecting 
this  flap  we  may,  toward  the  back,  cut  the  external  jugular  vein, 
and  this  should  be  clamped  and  tied.  The  deep  fascia  is  then  incised 
and  the  submaxillary  gland  exposed.  This  gland,  which  is  lodged 
in  a  bed  of  loose  connective  tissue,  is  seized  with  toothed  forceps 
and  enucleated,  together  with  the  adjoining  lymphatic  nodes.  This 
is  accomplished  by  cutting  with  the  knife  close  to  the  gland  or  by 
blunt  dissection  with  the  handle  of  the  knife  or  with  the  finger, 
the  gland  being  finally  cut  away  from  its  duct,  which  disappears 
anteriorly  beneath  the  posterior  border  of  the  mylo-hyoid  muscle  on 
its  way  to  open  into  the  anterior  part  of  the  floor  of  the  mouth. 
The  facial  artery,  if  not  previously  cut,  is  usually  divided  in  enucleat- 
ing this  gland,  and  should  be  tied  when  cut,  or,  still  better,  it  may 
be  tied,  before  it  is  cut,  close  to  its  origin  and  before  it  reaches  the 
submaxillary  gland. 


OPERATIONS  UPON  THE  TONGUE.  159 

The  facial  vein  is  also  usually  divided  during  this  part  of  the 
operation;  this  vessel  bleeds  freely,  hut  may  be  clamped  and  ligated. 
After  the  submaxillary  gland  has  been  removed,  the  boundaries  of 
the  submaxillary  triangle  are  readily  made  out;  above,  the  lower 
border  of  the  jaw,  and,  below,  in  front,  and  behind,  the  anterior  and 
posterior  bellies  of  the  digastric  muscle.  The  floor  of  the  submaxil- 
lary triangle  is  formed  in  front  by  the  oblique  fibers  of  the  mylo- 
hyoid and  behind  by  the  perpendicular  fibers  of  the  hyo-glossus, 
which  muscle  lies  on  a  deeper  plane  than  the  mylo-hyoid,  being 
partly  overlapped  by  the  posterior  margin  of  the  latter.  Passing 
from  behind,  horizontally  forward,  above  and  parallel  with  the  hyoid 
bone  and  lying  directly  upon  the  hyo-glossus  muscle  is  the  hypo- 
glossal nerve;  this  nerve  disappears  anteriorly  beneath  the  poste- 
rior edge  of  the  mylo-hyoid  muscle.  This  nerve  marks  the  upper 
boundary  of  the  lingual  triangle,  which  is  really  the  apex  of  the 
submaxillary  triangle.  The  base  of  the  lingual  triangle  is  formed 
by  the  hypoglossal  nerve,  and  its  lower  borders,  in  front  and  behind, 
by  the  anterior  and  posterior  bellies  of  the  digastric.  The  floor  of 
the  lingual  triangle  is  formed  by  the  hyo-glossus,  and  beneath  this 
muscle  the  lingual  artery,  accompanied  by  a  vein,  is  located;  so  that, 
if  this  muscle  is  picked  up  with  tooth  forceps  and  snipped  through 
with  the  knife  or  scissors,  the  lingual  artery  is  readily  found  and 
may  be  hooked  up  with  an  aneurism  needle  and  tied.  Locating 
and  tying  the  lingual  artery  in  this  triangle  is  very  simple.  We  are 
then  ready  to  proceed  with  the  amputation  of  the  tongue. 

Should  it  be  desirable  to  tie  the  lingual  artery  without  remov- 
ing the  submaxillary  gland,  one  may,  after  cutting  through  the  deep 
fascia,  draw  the  gland  up  out  of  the  way  and  then  proceed  as  above. 
In  this  case  it  is  not  necessary  to  make  such  an  extensive  incision. 

OPERATIONS  UPON  THE  TONGUE. 

Amputation  of  the  Tongue  (Kocher),  with  Preliminary  Ligation 
of  the  Lingual  Artery. — Amputation  of  the  tongue  according  to  the 
method  of  Kocher  has  many  advantages:  the  hemorrhage  is  easily 
controlled,  diseased  glands  are  readily  removed,  and  the  incision  is 
well  placed  for  drainage. 

The  position  of  the  patient,  etc.,  has  been  described  in  connec- 
tion with  the  ligation  of  the  lingual  artery. 


160  NECK  AND  TONGUE. 

An  incision,  as  described  above  for  the  ligation  of  the  lingual 
artery,  is  made  upon  the  side  of  the  neck,  laying  bare  the  boundaries 
of  the  submaxillary  triangle.  The  lymphatic  nodes  and  submaxillary 
gland  are  then  excised  and  the  lingual  artery  sought  for  and  tied; 
it  is  not  necessary  to  ligate  the  lingual  of  each  side,  yet  this  may  be 
clone  with  advantage,  especially  if  the  lymphatics  of  both  sides  are 
involved,  as  they  can  then  be  extirpated  at  the  same  time  that  the 
vessel  is  ligated. 

After  having  excised  the  submaxillary  lymphatic  nodes  and 
gland  and  tied  the  lingual  artery  and  secured  all  bleeding  points, 
an  incision  is  made  with  the  knife  through  the  floor  of  the  sub- 
maxillary triangle, — i.e.,  through  the  mylo-hyoid  muscle  and  the 
mucous  membrane  of  the  mouth, — close  to  the  inner  surface  of  the 
body  of  the  lower  jaw.  This  opening  may  be  farther  enlarged  with 
the  scissors  or  fingers.  The  tip  of  the  tongue  is  then  seized  with  a 
forceps  and  drawn  out  into  the  wound  in  the  neck,  through  the 
opening  in  the  floor  of  the  mouth,  and  making  considerable  traction, 
first  to  one  side  and  then  to  the  other,  the  tongue  is  separated  from 
its  attachment  to  the  floor  of  the  mouth,  as  far  back  toward  the  base 
as  possible.  This  is  done  with  the  blunt-pointed  curved  scissors, 
snipping  through  the  septum  of  the  tongue  and  working  close  to  its 
under  surface.  During  this  step  of  the  operation,  and  while  traction 
is  being  made  upon  the  tongue,  one  should  examine  occasionally  with 
the  finger  for  bands,  etc.,  which  tend  to  bind  the  tongue  within  the 
mouth.  The  anterior  pillars  of  the  fauces,  which  are  attached  to  the 
sides  of  the  tongue,  near  its  base,  should  be  cut  close  to  the  surface 
of  the  tongue,  and  then  it  will  be  observed  that  the  organ  can  be 
drawn  out  of  the  mouth  for  a  considerable  distance,  when  it  may  be 
amputated  quite  close  to  its  root.    This  is  done  with  the  scissors. 

The  half  of  the  tongue,  corresponding  to  the  side  upon  which 
the  lingual  has  been  tied,  may  be  cut  through  without  occasioning 
any  bleeding;  but,  if  the  lingual  artery  of  the  other  side  has  not 
been  previously  tied,  the  hemorrhage,  when  this  second  half  of  the 
tongue  is  cut  through,  may  be  embarrassing,  as  there  may  be  some 
difficulty  in  catching  the  cut  end  of  the  artery.  This,  however,  may 
be  provided  against  by  seizing  the  base  of  the  tongue  with  a  toothed 
clamp  behind  the  point  where  it  is  intended  to  amputate  it  before 
cutting  through;  so  that,  when  we  divide  this  half  of  the  tongue, 
we  may  puli  the  stump  forward,  and  seize  the  divided  vessel,  when 
it  spurts,  with  an  artery  clamp. 


OPERATIONS  UPON  THE  TONGUE.  161 

The  wound  in  the  side  of  the  neck  may  he  closed  with  inter- 
rupted silk-worm  gut  sutures,  except  its  posterior  part,  which  is  left 
open  and  packed  to  carry  off  the  secretions,  etc.,  from  the  mouth. 
The  packing  should  he  introduced  well  into  the  cavity  of  the  mouth. 
The  patient  is  fed  through  a  stomach  tune,  which  is  passed  through 
the  mouth  or  through  the  nose.  This  tube  may  be  passed  before  the 
patient  recovers  from  the  ansesthetic. 

Amputation  of  the  Tongue  (Regnoli-Billroth). — This  method 
is  applicable  to  those  cases  where  the  floor  of  the  mouth  is  consid- 
erably involved  in  the  disease. 

The  patient  is  placed  in  the  Eose  position,  or  if  a  preliminary 
tracheotomy  has  been  done  and  a  Trendelenburg  tampon  cannula 
introduced  into  the  trachea,  or  if  an  ordinary  tracheotomy  tube  has 
been  introduced  and  the  pharynx  has  been  tamponed,  the  patient 
may  lie  in,  the  usual  position  with  the  shoulders  raised  and  the  head 
thrown  back. 

An  incision  is  made  along  the  lower  border  of  the  body  of  the 
jaw  about  6  cm.  long,  the  midpoint  of  the  incision  corresponding  to 
the  symphysis  mentis.  This  incision  penetrates  through  all  the  soft 
parts  down  to  the  bone  and  extends  backward,  upon  either  side, 
nearly  as  far  as  the  anterior  edge  of  the  masseter  muscle.  In  making 
this  incision,  the  facial  artery,  as  it  turns  up  over  the  lower  border 
of  the  jaw-bone,  just  in  front  of  the  masseter,  may  be  avoided. 

From  either  end  of  this  incision  additional  ones  are  made  which 
reach  straight  downward  as  far  as  the  hyoid  bone,  passing  through 
the  integument  and  the  platysma.  Through  the  lateral  incisions, 
on  either  side,  the  lingual  artery  may  be  sought  and  tied,  at  the 
same  time  extirpating  any  diseased  glands,  etc. 

The  cavity  of  the  mouth  is  now  entered  by  severing  the  muscles 
attached  to  the  inner  surface  of  the  body  of  the  lower  jaw  with  a 
knife.  They  should  be  cut  fairly  close  to  the  bone,  and  the  point 
of  the  knife  may  be  guided  with  the  finger  in  the  mouth.  Those 
muscles  that  are  attached  to  the  inner  aspect  of  the  symphysis 
in  the  middle  line  are  divided  first.  A  suture  should  be  passed 
through  the  tip  of  the  tongue  or  it  may  be  seized  with  a  toothed 
clamp  in  order  to  exercise  traction  and  prevent  its  falling  back  into 
the  pharynx  and  obstructing  the  breathing  during  the  course  of  the 
operation. 

After  a  sufficiently  large  opening  has  been  made  in  the  floor 
of  the  mouth,  the  tongue  is  drawn  through  the  wound,  under  the 


162  NECK  AND  TONGUE. 

jaw,  and  may  then  be  removed  together  with  the  floor  of  the  mouth 
as  far  back  as  the  epiglottis. 

If  the  lingual  arteries  have  not  been  previously  ligated,  the  base 
of  the  tongue  should  be  seized  with  a  vulsella  forceps  before  it  is 
amputated,  in  order  to  facilitate  the  clamping  of  these  vessels  in  the 
stump  of  the  tongue. 

The  flap  of  skin  and  soft  parts  is  replaced  and  the  wound  closed 
except  posteriorly,  on  one  or  both  sides,  where  the  incision  is  left 
open  and  packed  in  order  to  drain  the  cavity  of  the  mouth. 

Extirpation  of  the  Tongue  through  the  Floor  of  the  Mouth,  with 
Division  of  the  Lower  Jaw. — The  operation  is  preceded  by  a  trache- 
otomy and  the  introduction  of  a  Trendelenburg  tampon  cannula, 
or  an  ordinary  tracheotomy  tube  may  be  used  and  the  pharynx  tam- 
poned. A  soft  rubber  tube  for  feeding  purposes  may  be  passed  into 
the  stomach,  before  the  patient  recovers  from  the  anaesthetic,  either 
through  the  mouth  or  the  nose. 

Sedillot's  Method,  with  Division  of  the  Lowek  Jaw  in  the 
Middle  Line. — The  first  incisor  tooth  of  the  lower  jaw  is  extracted. 
An  incision  is  made,  as  in  the  Eegnoli-Billroth  operation,  along  the 
lower  border  of  the  jaw  and  reaching  as  far  as  the  masseter  on  either 
side.  The  lower  lip  is  then  split  in  the  middle  line,  the  incision  being 
carried  down  to  the  bone  through  the  gum  and  periosteum.  The 
lower  jaw  is  then  sawn  through  with  a  metacarpal  or  a  chain  or  a 
Gigli  saw,  and  the  muscles  and  the  mucous  membrane  composing  the 
floor  of  the  mouth  incised  close  to  the  inner  surface  of  the  body  of 
the  lower  jaw-bone. 

Each  half  of  the  jaw  is  now  drawn  well  outward,  away  from  the 
middle  line,  thus  giving  very  free  access  to  the  tongue  and  to  the 
floor  of  the  mouth.  The  tongue  and  that  part  of  the  floor  of  the 
mouth  which  is  involved  in  the  disease  may  then  be  extirpated. 

If  the  Unguals  have  not  been  previously  tied,  they  may  be 
clamped  after  the  tongue  has  been  amputated,  drawing  the  stump 
of  the  tongue  forward  with  a  vulsella  in  order  to  facilitate  this. 

The  tonsils  and  the  pillars  of  the  fauces  may  also  be  reached 
in  this  operation,  and,  if  the  lower  jaw-bone  is  involved,  it  can  be 
resected  in  part.  Diseased  lymphatic  glands  in  the  neck  may  also 
be  excised  through  this  incision,  which  may  be  made  as  extensive 
as  necessary. 

One  should  attempt  to  bring  the  raw  surfaces  in  the  mouth 
together,  at  least  in  part,  with  interrupted  chromicized  catgut  or 


OPERATIONS  UPON  THE  TONGUE.  163 

silk  sutures,  their  ends  being  left  long  to  facilitate  their  removal 
later. 

The  two'  halves  of  the  jaw  are  brought  together  and  carefully- 
wired,  and  the  incision  closed  except  at  its  posterior  part  on  one  or 
both  sides,  where  it  is  left  open  for  packing  and  drainage. 

Langenbeck's  Method,  with  Division  of  the  Lower  Jaw 
on  one  Side. — Upon  the  side  corresponding  to  the  disease  an  in- 
cision is  carried  from  the  corner  of  the  mouth  through  the  lower 
lip  as  far  as  the  lower  border  of  the  jaw,  whence  it  is  continued 
downward  through  the  integument  of  the  neck  as  far  as  the  side 
of  the  hyoid  bone.  The  upper  part  of  this  incision  splits  the  lip 
and  gum,  passing  through  the  periosteum  down  to  the  bone;  the 
lower  part  of  the  incision  passes  through  the  skin,  fat,  and  platysma. 
All  bleeding  points  are  clamped. 

Through  the  lower  part  of  the  incision,  after  cutting  through 
the  deep  fascia,  the  submaxillary  gland  and  the  neighboring  dis- 
eased lymphatic  nodes  of  this  side  may  be  removed,  and  the  lingual 
artery  tied  as  it  lies  in  the  lingual  triangle,  above  the  hyoid  bone 
and  beneath  the  hyo-glossus  muscle. 

The  canine  tooth  of  the  lower  jaw  is  now  extracted  and  an  open- 
ing made  in  the  floor  of  the  mouth  so  as  to  allow  the  use  of  the  chain 
or  wire  saw  with  which  the  jaw-bone  is  divided.  The  section  through 
the  jaw  should  be,  not  straight  up  and  down,  but  obliquely  from 
above  downward  and  inward  toward  the  symphysis,  so  that  the  tend- 
ency to  dislocation  caused  by  the  pull  of  the  masseter  muscle  may 
thus  be  counteracted.  The  jaw-bone  may  be  divided  with  a  narrow, 
flat  saw  or  with  a  chain  or  wire  saw. 

The  segments  of  the  divided  jaw-bone,  especially  the  shorter 
piece,  are  now  drawn  well  apart  with  sharp  retractors,  and  the  soft 
parts,  muscles  and  mucous  membrane,  which  form  the  floor  of  the 
mouth,  separated  from  their  attachment  to  the  inner  surface  of  the 
bone,  as  far  back,  if  need  be,  as  the  anterior  pillars  of  the  fauces. 
The  tongue  is  then  seized  with  the  toothed  forceps  and  drawn  well 
forward  and  over  toward  the  well  side  and  removed.  One  may  ex- 
cise the  floor  of  the  mouth,  the  pillars  of  the  fauces,  and  the  tonsils, 
if  they  are  diseased,  and  also  resect  a  part  of  the  jaw-bone  if  this 
is  involved. 

If  the  Unguals  have  not  been  previously  ligated,  we  may  clamp 
them  in  the  stump  after  the  tongue  has  been  amputated.  The  seg- 
ments of  the  jaw-bone  are  brought  into  apposition  and  wired,  and 


164  NECK  AND  TONGUE. 

the  wound  in  the  soft  parts,  except  its  lower  part,  which  is  left  open 
and  packed  to  carry  off  the  secretions  from  the  mouth,  is  closed  with 
interrupted  silk-worm  gut  sutures. 

One  should  try  to  diminish  the  raw  surface  left  in  the  buccal 
cavity  as  much  as  possible  by  drawing  the  parts  together  with'  sepa- 
rate chromicized  catgut  sutures. 

Billeoth's  Method,  with  Bilateeal  Division  of  the  Lowee 
Jaw. — This  is  probably  not  so  satisfactory  as  the  preceding  opera- 
tions, owing  to  the  difficulty  of  getting  union  of  the  loose  segment 
of  the  jaw. 

The  canine  tooth  upon  either  side  of  the  lower  jaw  is  extracted, 
and  an  incision  made  from  each  corner  of  the  mouth,  through  the 
lower  lip,  gum,  and  periosteum,  down  to  the  bone,  and  continued 
downward,  in  the  neck,  through  the  skin,  fat,  and  platysma  as  far 
as  the  hyoid  bone. 

Corresponding  to  the  place  upon  either  side  where  the  canine 
tooth  has  been  extracted  the  lower  jaw  is  sawn  through,  from  its 
upper  border  downward  to  its  lower  border;  this  may  be  done  with 
the  chain,  wire,  or  flat  saw. 

The  soft  parts,  which  correspond  to  the  floor  of  the  mouth  and 
which  are  attached  to  the  middle,  loose  segment  of  the  jaw-bone,  are 
separated  upon  the  inner  aspect  of  the  bone,  and  the  flap  of  soft 
parts,  which  includes  the  free  middle  segment  of  the  bone,  is  re- 
flected downward. 

The  lingual  arteries  may  be  ligated  and  diseased  glands  re- 
moved through  the  incisions  in  the  neck  previous  to  amputating  the 
tongue,  or  the  arteries  may  be  clamped  and  ligated  in  the  stump 
after  the  tongue  has  been  cut  away.  We  gain  free  access  to  the 
floor  of  the  mouth,  tonsils,  etc.,  in  this  operation. 

The  segments  of  the  jaw  are  finally  wired  together  and  the 
incisions  closed  except  the  lower  part,  upon  one  or  both  sides,  which 
may  be  left  open  and  packed  for  drainage. 

Extirpation  of  Half  of  the  Tongue  (Whitehead). — The  patient 
may  be  placed  in  a  half-sitting  posture.  Anaesthesia  is  not  complete. 
A  liberal  dose  of  morphin  may  be  administered  hypodermically 
shortly  before  the  operation,  and  only  sufficient  chloroform  used  to 
keep  the  patient  fairly  quiet.  In  this  way  sufficient  reflex  is  retained 
to  enable  the  patient  to  keep  the  larynx  clear  of  blood  by  coughing 
and  expectorating. 

This  operation  is  advisable  when  only  half  of  the  tongue  is  to 


OPERATIONS  UPON  THE  TONGUE.  165 

be  removed,  or,  if  the  whole  tongue  is  to  be  extirpated,  where  the 
disease  is  limited  and  has  not  involved  the  floor  of  the  mouth. 

One  or  both  lingual  arteries  may  be  previously  tied  through  a 
small  incision  upon  either  side  of  the  neck. 

The  jaws  are  separated  with  a  gag  and  the  mouth  held  wide  open 
with  flat  retractors  placed  in  either  corner.  A  strong  silk  suture  is 
passed  through  the  tip  of  the  tongue,  and  with  this  as  a  tractor  the 
tongue  is  drawn  well  forward  and  split  down  the  middle  with  sharp 
scissors.  The  diseased  half  of  the  tongue  is  then  separated  from  the 
floor  of  the  mouth  and  amputated  as  far  back  toward  the  root  of 
the  organ  as  desired.  If  the  lingual  artery  has  not  been  tied  as  a 
preliminary  step  to  the  operation,  the  bleeding  vessel  must  be  seized 
with  the  artery  forceps  in  the  stump  of  the  tongue  and  ligated.  In 
excising  a  portion  of  the  tongue  one  should  cut  wide  of  the  apparent 
diseased  area.  If  the  disease  has  approached  near  the  middle  line 
it  is  probably  better  to  sacrifice  the  whole  tongue,  in  which  case  the 
second  half  of  the  tongue  may  be  amputated  in  a  similar  manner. 

This  operation  will  probably  suffice  for  early  cases  where  the 
floor  of  the  mouth  and  the  lymphatics  are  not  yet  involved. 


PART  IV. 

THE  THORAX. 


THE  SURGICAL  ANATOMY  OF  THE  THORACIC  WALL. 

The  Skeleton  of  the  Thorax. — The  thorax  consists  of  a  conical 
cage  of  bone  and  cartilage.  Entering  into  its  construction  are  the 
dorsal  vertebrae,  ribs,  sternum,  and  interposed  costal  cartilages.  The 
spaces  between  the  ribs  and  costal  cartilages  are  filled  in,  and  the 
walls  of  the  chest  thus  completed,  by  the  intercostal  muscles. 

The  thoracic  cavity  is  rather  cone-shaped,  with  its  base  below 
and  its  small  end  above,  and  is  somewhat  flattened  from  before  back- 
ward. 

The  upper  orifice  of  the  thorax  is  kidney-shaped,  narrow  from 
before  backward,  and  broader  from  side  to  side.  It  is  bounded  in 
front  by  the  upper  border  of  the  sternum,  behind  by  first  dorsal 
vertebra,  and  laterally,  on  each  side,  by  the  first  rib.  The  first  rib 
is  set  very  obliquely;  so  that  its  anterior  end  strikes  a  much  lower 
level  than  its  posterior  end.  The  upper  border  of  the  sternum  is 
opposite  the  intervertebral  cartilage  between  the  second  and  third 
dorsal  vertebras. 

The  lower  opening  of  the  thorax  is  large.  It  is  bounded  by  the 
lower  border  and  tip  of  the  twelfth  rib,  the  tip  of  the  eleventh  and 
the  costal  cartilages  of  the  tenth,  ninth,  eighth,  and  seventh  ribs. 
Anteriorly,  in  the  middle  line,  is  the  ensiform  cartilage;  posteriorly 
is  the  body  of  the  last  dorsal  vertebra. 

A  transverse  section  through  the  middle  of  the  thoracic  cavity 
shows  it  to  be  rather  heart-shaped,  owing  to  the  projection  forward 
of  the  bodies  of  the  vertebras.  On  either  side  of  the  vertebral  col- 
umn there  is  a  longitudinal  recess,  which  serves  to  deepen  the  space 
for  the  accommodation  of  the  lungs;  this  is  called  the  fossa  pul- 
monis. The  cartilages  of  the  lower  ribs,  the  seventh  to  the  tenth, 
meet  at  the  lower  end  of  the  sternum  and  form  an  angle  the  apex 
of  which  corresponds  to  the  ensiform  cartilage.  This  is  known  as 
the  costal  angle. 

The  thoracic  cavity  is  closed  in,  below,  by  the  diaphragm,  which 
projects  upward,  dome-like,  into  the  cavity  of  the  chest,  forming  its 
(166) 


SURGICAL  ANATOMY  OF  THE  THORACIC  WALL.  167 

floor  and  at  the  same  time  the  roof  of  the  abdominal  cavity.  By  the 
projection  of  the  diaphragm  upward  into  the  chest  the  capacity  of 
the  chest  cavity  is  diminished  and  that  of  the  abdomen  correspond- 
ingly increased.  In  the  living  body  the  chest  appears  to  be  broader 
above,  at  the  shoulders,  than  below  at  the  waist;  this  appearance  is 
due  to  the  broad  shoulder  girdle,  which  partially  encircles  the  chest 
above  and  which  is  made  up  of  the  clavicle  and  the  scapula  of  either 
side. 

The  space  within  the  chest  consists  of  an  air-tight  compartment 
on  either  side,  each  containing  one  of  the  lungs,  and  a  middle  space 
called  the  mediastinum,  in  which  are  lodged  the  heart  and  the  great 
vessels  at  its  base,  the  trachea,  oesophagus,  thoracic  duct,  and  the 
thymus  gland  or  its  remains. 

The  Doksal  Vektebk^;.  —  These  are  twelve  in  number  and 
form  the  back  part  of  the  skeleton  of  the  chest.  They  give  stability 
to  the  thorax  and  at  the  same  time,  on  account  of  the  presence  of 
the  elastic  intervertebral  pads,  free  motion  is  allowed  in  all  direc- 
tions. 

This  part  of  the  vertebral  column  shows  a  sagittal  curve  with 
its  concavity  forward  and  a  slight  lateral  curve  with  its  concavity 
toward  the  left  (aorta). 

The  Eibs  are  twelve  in  number  (may  be  eleven  or  thirteen)  on 
each  side.  They  are  flat  bones  articulated  behind  to  the  vertebrae 
and  directed  obliquely  downward  and  forward.  They  form  the  bony 
frame-work  of  the  back,  sides,  and  part  of  the  front  of  the  chest. 

The  lower  the  rib  is  situated,  the  greater  is  its  inclination  down- 
ward.   They  increase  in  length  from  the  first  to  the  eighth. 

The  first  to  the  seventh  are  true  ribs:  i.e.,  they  are  each  con- 
nected individually,  through  their  cartilages,  with  the  sternum. 

The  eighth  to  the  twelfth  are  false  ribs:  their  cartilages  do  not 
articulate  with  the  sternum.  The  eighth,  ninth,  and  tenth  ribs  are 
indirectly  connected  with  the  sternum  through  the  junction  of  their 
respective  costal  cartilages  with  those  of  the  ribs  which  immediately 
adjoin  them  above. 

The  eleventh  and  twelfth  are  floating  ribs;  they  are  short  and 
their  cartilages  are  free. 

The  lower  border  of  each  rib,  upon  its  inner  aspect,  is  grooved 
for  the  lodgment  of  the  corresponding  intercostal  vein,  artery,  and 
nerve,  that  being  their  order  from  above  downward. 

The  first  rib  is  important  surgically.     It  is  very  short,  and  its 


168  THORAX. 

surfaces  look  almost  directly  upward  and  downward.  It  is  set  so 
obliquely  that  its  posterior  end,  head,  articulates  with  the  upper 
part  of  the  body  of  the  first  dorsal  vertebra,  whereas  its  anterior 
end,  at  its  attachment  to  the  sternum,  is  upon  a  level  with  the  inter- 
vertebral pad  between  the  second  and  third  dorsal  vertebras.  The 
inner  border  of  this  rib  presents  a  tubercle  for  the  attachment  of 
the  scalenus  anticus  muscle;  external  to  this  tubercle,  upon  the 
upper  surface  of  the  rib,  there  is  a  groove  for  the  subclavian  artery. 
The  subclavian  vein  also  passes  across  the  upper  surface  of  the  first 
rib,  but  internally  to  the  artery,  the  tendon  of  the  scalenus  anticus 
being  interposed  between  the  two  vessels. 

The  inner  border  of  the  first  rib  is  in  direct  relation  with  the 
dome  of  the  pleura  and  the  apex  of  the  lung. 

The  Costal  Caetilages. — These  are  the  elastic  bands  which 
join  the  ribs  to  the  sternum  (except  the  eleventh  and  twelfth).  The 
cartilage  of  the  first  rib  is  very  short.  The  first  and  second  costal 
cartilages,  as  they  pass  to  the  sternum,  are  directed  somewhat  down- 
ward like  their  ribs.  The  cartilage  of  the  second  rib  articulates 
with  the  sternum  at  the  junction  of  the  manubrium  with  the  glad- 
iolus. The  cartilage  of  the  third  rib  is  directed  horizontally;  the 
cartilages  of  the  fourth,  fifth,  sixth,  and  seventh  ribs  are  directed 
upward  with  increasing  obliquity  as  they  pass  to  the  sternum.  The 
cartilages  of  the  eighth,  ninth,  and  tenth  make  quite  a  sharp  turn 
upward  toward  the  sternum  at  the  angle  of  junction  with  their  ribs, 
and  do  not  reach  the  sternum  directly,  but  are  fixed  each  to  the 
cartilage  immediately  above,  and  finally,  through  the  junction  of  the 
cartilage  of  the  eighth  rib  with  that  of  the  seventh,  to  the  sternum. 
The  cartilages  of  the  eleventh  and  twelfth  ribs  are  short  and  free. 

The  Steknttm. — This  bone  is  rarely  fractured,  owing  to  the 
elasticity  of  the  parts  with  which  it  articulates.  It  consists  of  a 
manubrium,  or  handle;  a  gladiolus,  or  body;  and  a  cartilaginous  tip, 
the  ensiform  or  xiphoid  cartilage.  The  junction  between  the  manu- 
brium and  the  body  is  marked  by  a  prominent  transverse  line,  and 
presents  an  angle  directed  forward:  angulus  Ludovici.  This  trans- 
verse ridge,  which  is  readily  felt  under  the  skin,  is  an  important 
landmark  in  counting  the  ribs:  it  corresponds  to  the  articulation  of 
the  costal  cartilage  of  the  second  rib  with  the  sternum. 

The  ensiform  cartilage  varies  in  length  and  shape;  its  lower 
extremity  is  usually  on  a  level  with  the  tenth  dorsal  vertebra;  it 
may  be  bifurcated  or  deflected  to  one  side.     The  junction  of  the 


SURGICAL  ANATOMY  OF  THE  THORACIC  WALL.  169 

ensiform  cartilage  with  the  body  of  the  sternum  corresponds  with 
the  line  that  marks  the  lower  border  of  the  heart  as  it  lies  within 
the  chest  behind  the  sternum. 

The  Muscles  of  the  Chest  Wall.  The  Inteecostal  Muscles 
are  placed  between  the  ribs  and  costal  cartilages,  and  consist  of  two 
sets:    external  and  internal. 

The  External  Intercostals.  —  The  fibers  of  the  external  inter- 
costals  have  a  direction  similar  to  those  of  the  external  oblique 
muscle  of  the  abdomen:  that  is,  from  above  downward  and  forward. 
In  front,  between  the  costal  cartilages,  the  muscular  fibers  are  ab- 
sent, their  place  being  taken  by  aponeurotic  bands,  the  ligamenta 
intercostalia  anterior,  which  represent  the  muscles. 

The  Internal  Intercostals. — The  direction  of  the  fibers  of  the 
internal  intercostal  muscles  is  the  reverse  of  those  of  the  external. 
They  correspond  to  the  internal  oblique  muscle  of  the  abdomen, 
and  their  fibers  have  a  similar  direction:  upward  and  forward.  Be- 
hind, the  internal  intercostals  are  deficient,  their  place  being  occu- 
pied by  aponeurotic  sheaths:    the  ligamenta  intercostalia  posterior. 

The  Teiangttlaeis  Steeni  is  situated  anteriorly  within  the 
chest.  It  is  a  thin  sheet  of  muscle  which  is  attached  along  the 
lateral  border  of  the  posterior  aspect  of  the  sternum.  It  spreads 
upward  and  outward  in  four  or  five  processes,  which  are  attached 
separately  to  the  inner  surfaces  of  the  cartilages  of  the  second  to 
the  sixth  ribs.  The  internal  mammary  artery  is  located  between 
this  muscle  and  the  costal  cartilages.  The  triangularis  sterni  is  the 
transversus  thoracis  anterior  of  Henle. 

The  Musculi  Stjbcostales  are  a  few  sets  of  muscular  fibers 
that  are  found  upon  the  internal  surfaces  of  the  posterior  ends  of 
the  ribs  near  the  vertebral  column;  the  direction  of  the  fibers  of 
these  muscles  is  similar  to  that  of  the  internal  intercostals:  they 
reach  from  the  inner  surface  of  one  rib  to  the  first  or  second  rib 
above.  These  muscles  correspond  to  the  musculus  transversus 
thoracis  posterior  of  Henle,  and  together  with  the  triangularis  sterni 
are  the  analogues  of  the  transversus  abdominis,  the  most  internal, 
deepest,  of  the  flat  muscles  of  the  abdomen. 

The  Fasciae  of  the  Chest. — A  thin  fascia  covers  the  outer  surface 
of  the  ribs  and  the  external  intercostals.  A  similar  fascia  is  spread 
over  the  inner  surface  of  the  ribs  and  the  internal  intercostals,  tri- 
angularis sterni,  and  subcostales.  This  fascia  corresponds  to  the 
fascia  transversalis  of  the  abdomen,  and  is  known  as  the  fascia  endo- 


170  THORAX. 

thoracica.  The  fascia  endothoracica  is  also  spread  over  the  thoracic 
surface  of  the  diaphragm.  It  lines  the  whole  inner  surface  of  the 
thoracic  cavity,  and  is  everywhere  interposed  between  the  parietal 
layer  of  the  pleura  and  the  inner  surface  of  the  chest,  serving  thus 
to  bind  the  pleura  to  the  chest  wall  and  at  the  same  time  to 
strengthen  it.  Upon  the  posterior  surface  of  the  sternum  this  fascia 
iorms  a  strong  fibrous  layer.  Above  it  projects  into  the  root  of 
the  neck  together  with  the  dome  of  the  pleura,  which  it  strengthens 
and  fixes  to  the  vertebrae  and  to  the  deep  surface  of  scaleni  muscles, 
etc. 

The  Internal  Mammary  Artery  supplies  the  front  part  of  the 
intercostal  spaces  and  the  diaphragm  and  gives  perforating  branches 
to  the  muscles  of  the  chest  and  to  the  mammary  gland.  At  its  origin 
from  the  first  part  of  the  subclavian  artery  it  lies  behind  the  sub- 
clavian vein,  resting  upon  the  pleura,  and  is  crossed  by  the  phrenic 
nerve.  It  passes  down  into  the  thoracic  cavity  and  descends  along- 
side of  the  sternum,  a  distance  of  from  5  to  10  mm.  intervening 
between  it  and  the  lateral  border  of  this  bone.  Behind  the  seventh 
costal  cartilage  the  internal  mammary  artery  divides  into  the 
musculo-phrenic  and  the  superior  epigastric.  The  musculo-phrenic 
continues  downward  parallel  with  the  free  border  of  the  ribs,  sup- 
plying branches  to  the  intercostal  spaces.  The  superior  epigastric 
enters  the  posterior  sheath  of  the  rectus,  anastomosing  with  the  deep 
epigastric,  which  is  derived  from  the  external  iliac,  and  in  this  way 
forms  an  important  communication  between  this  trunk  and  the  sub- 
clavian. The  internal  mammary  artery  is  accompanied  by  two  veins, 
one  upon  either  side,  but  above  these  two  unite  to  form  a  single 
vein,  which  lies  to  the  inner  side  of  the  artery.  The  artery  is  also 
accompanied  by  a  chain  of  lymphatic  glands. 

Within  the  chest  the  artery  rests  upon  the  costal  cartilages  and 
the  internal  intercostal  muscles,  alongside  the  sternum,  and  is  sepa- 
rated from  the  parietal  pleura  by  the  fascia  endothoracica  and  the  tri- 
angularis sterni  muscle.  Opposite  each  intercostal  space  the  internal 
mammary  gives  off  an  intercostal  branch,  which,  passing  outward, 
divides  into  two,  and  these,  anastomosing  with  the  intercostal 
branches  from  the  aorta,  serve  to  establish  a  communication  between 
the  subclavian  and  the  aorta.  These  intercostal  branches  are  located 
between  the  internal  and  the  external  intercostal  muscles  close  to 
the  upper  and  lower  borders  of  the  contiguous  ribs.  The  internal 
mammary  gives  off  perforating  branches,  which  pass  forward  through 


REGIONS  OF  THE  CHEST.  171 

the  intercostal  spaces  to  supply  the  muscles  of  the  hreast  and  the 
mammary  glands.  Those  which  pass  through  the  second,  third,  and 
fourth  intercostal  spaces  are  large,  and  are  distributed  to  the  mam- 
mary gland. 

The  Diaphragm. — The  lower  orifice  of  the  thorax  is  closed  in 
by  the  diaphragm.  This  is  a  musculo-tendinous  partition  which 
separates  the  thorax  from  the  abdominal  cavity.  It  forms  the  floor 
of  the  thoracic  cavity  and  the  roof  of  the  abdomen.  The  thoracic 
surface  of  the  diaphragm  is  covered  by  the  fascia  endothoracica  and 
the  diaphragmatic  portion  of  the  parietal  pleura.  Its  middle  part 
from  before  backward  forms  the  floor  of  the  mediastinum,  and  upon 
either  side  of  this  it  forms  the  bottom  of  each  pleural  cavity. 

The  position  of  the  diaphragm,  immediately  after  death,  corre- 
sponds with  that  found  at  the  end  of  quiet  expiration  during  life, 
but  after  a  short  time,  owing  to  the  further  collapse  of  the  lungs, 
it  reaches  to  a  still  higher  level. 

Luschka  places  the  highest  point  reached  by  the  diaphragm 
at  the  end  of  forced  expiration  upon  the  right  side  at  the  level  of 
the  fourth  rib.  Most  authors  say  that  this  is  too  high  and  give,  in- 
stead, the  fourth  intercostal  space.  Upon  the  left  side  the  dia- 
phragm does  not  reach  as  high  as  upon  the  right  by  the  breadth 
of  one  rib. 

The  upper  orifice  of  the  thoracic  cavity  is  shut  in  on  either  side 
by  the  arching  subclavian  artery,  scalenus  anticus  and  medius  mus- 
cles, and  the  fascia  endothoracica.  This  fascia  is  intimately  blended 
with  the  dome  of  the  pleura,  and  attaches  the  same  to  the  adjacent 
fixed  points. 

THE  REGIONS  OF  THE  CHEST. 

The  following  imaginary  lines  serve  to  facilitate  the  location  of 
points  upon  the  chest: — 

1.  The  midsternal,  which  passes  through  the  middle  of  the 
sternum. 

2.  The  lateral  sternal,  which  corresponds  to  the  lateral  border 
of  the  sternum. 

3.  The  mammary,  which  is  drawn  through  the  nipple. 

4.  The  parasternal,  which  is  drawn  midway  between  the  lateral 
horder  of  the  sternum  and  the  mammary  line. 

5.  The  axillary,  which  is  located  midway  between  the  anterior 
and  the  posterior  borders  of  the  axilla. 


172  THORAX. 

6.   The  scapular  passes  through  the  lower  angle  of  the  scapula. 
The  chest  is  divided  into  a  number  of  regions  as  follows: — - 

1.  The  sternal. 

2.  The  upper  anterior  pectoral,  which  is  subdivided  into  a 
clavicular,  an  infraclavicular,  and  a  mammary. 

3.  The  lower  anterior  pectoral. 

4.  The  lateral  pectoral. 

The  Sternal  Region.- — This  region  corresponds  to  the  sternum- 
It  is  depressed  below  the  level  of  the  rest  of  the  chest,  especially 
in  muscular  subjects  and  in  females. 

The  skin  of  this  region,  in  the  male,  is  usually  covered  with  hair 
and  is  rich  in  sweat-glands.  The  subcutaneous  tissue  is  poor  in  fat 
and  allows  ready  palpation  of  the  sternum  beneath.  The  skin  and 
periosteum  covering  the  sternum  are  so  intimately  blended  with  each 
other  that  separation  between  these  two  layers  is  somewhat  difficult,, 
and,  therefore,  collections  of  blood  or  pus  beneath  the  skin  in  this 
region  remain  circumscribed,  as  is  the  case  in  the  subcutaneous  tissue 
of  the  scalp.  Above,  we  observe  the  upper  notched  border  of  the- 
sternum  with  the  sterno-clavicular  articulation  upon  either  side  and 
the  attachment  of  the  tendon  of  the  sterno-mastoid.  Below  is  the 
ensiform  cartilage,  to  which  is  attached  the  linea  alba.  The  junction 
of  the  manubrium  with  the  body  of  the  sternum  is  marked  by  a 
prominent  transverse  ridge  and  presents  an  angle  directed  forward: 
the  angle  of  Ludovici.  The  sternum  forms  the  anterior  wall  of  the- 
mediastinal  space,  and  its  posterior  surface  is  in  close  relation  with 
the  pleura  and  the  edges  of  the  lungs.  Below,  the  heart,  inclosed 
in  the  pericardial  sac,  lies  close  behind  the  sternum. 

The  Upper  Anterior  Pectoral  Region. — This  area  corresponds  to 
the  region  of  the  pectoralis  major  muscle,  and  shows  the  prominence 
of  the  breast  surmounted  by  the  nipple  and  the  areola.  The  skin  is 
soft,  especially  in  women,  and  during  lactation  is  marked  by  blue 
lines,  which  correspond  to  large  superficial  veins.  The  skin  is  freely 
movable,  owing  to  the  looseness  of  the  subcutaneous  tissue,  which 
is  rich  in  fat  and  within  which  the  mammary  gland  is  contained. 
The  mammary  gland  is  freely  movable  upon  the  underlying  pec- 
toralis major  muscle.  The  anterior  surface  of  the  pectoralis  major 
is  covered  by  a  thin,  cellular  fascia,  which  also  lines  the  posterior 
aspect  of  this  muscle.  Beneath  the  pectoralis  major  are  the  pec- 
toralis minor  and  the  subclavius  muscle.  The  pectoralis  major  and. 
minor  form  the  front  wall  of  the  axilla. 


REGIONS  OF  THE  CHEST.  173 

The  Pectoealis  Majoe  is  a  broad,  flat  muscle  which  occupies 
all  of  this  region.  It  takes  its  origin  from  the  cartilages  of  the  six 
or  seven  upper  ribs  and  from  the  edge  of  the  sternum:  the  sternal 
portion  of  the  muscle.  It  also  arises  from  the  inner  half  of  the 
anterior  surface  of  the  clavicle:  the  clavicular  portion  of  the  mus- 
cle. From  these  points  of  origin  the  fibers  converge  to  form  a  flat 
tendon,  about  two  inches  broad,  which  is  attached  to  the  outer  edge 
or  lip  of  the  bicipital  groove:  a  depression  which  marks  the  upper 
part  of  the  front  of  the  humerus.  The  pectoralis  major  muscle  is 
covered  by  a  thin  fascia,  which  dips  down  between  its  fasciculi  and 
from  which  the  overlying  fat  and  mammary  gland  are  readily  sepa- 
rated. This  fascia  is  rich  in  lymphatics,  which  may  become  involved 
in  disease  of  the  mammary  gland.  Below,  this  fascia  is  continuous 
with  the  superficial  fascia  which  covers  the  abdominal  muscles  and 
laterally  with  that  which  covers  the  serratus  magnus.  It  dips  down 
into  the  space  between  the  deltoid  and  the  pectoralis  major,  and  is 
there  continuous  with  the  loose  fascia  that  invests  the  pectoralis 
minor  and  the  posterior  surface  of  the  pectoralis  major. 

The  Pectoealis  Minor. — This  muscle  is  exposed  by  dividing 
the  tendon  of  the  pectoralis  major  close  to  its  insertion  and  reflect- 
ing the  muscle  downward.  The  pectoralis  minor  arises  from  the  tip 
of  the  coracoid  process;  passing  downward  and  inward  and  becoming 
broader,  it  is  attached  to  the  third,  fourth,  and  fifth  ribs.  The 
pectoralis  minor  is  invested  by  a  fascia  which  is  continued  upward 
and  inward  beyond  the  upper  border  of  the  muscle,  covering  in  the 
first  part  of  the  axillary  artery  and  adjoining  structures  and  the  sub- 
clavius  muscle.  This  layer  of  fascia  is  called  the  costo-coracoid 
membrane  and  is  attached  to  the  under  surface  of  the  clavicle  and 
to  the  first  rib.  It  is  somewhat  thickened,  and  perforated  by  various 
vascular  and  nervous  branches,  which  pass  to  and  from  the  axillary 
vessels  and  adjacent  nerves. 

The  Subclavius  Muscle. — This  muscle  is  exposed  after  the 
costo-coracoid  membrane  has  been  removed.  It  arises  from  the 
under  surface  of  the  clavicle  and  passing  downward  and  inward  is 
attached  to  the  cartilage  of  the  first  rib. 

This  upper  anterior  pectoral  region  may  be  considered  as  the 
clavicular,  the  infraclavicular,  and  the  mammary  regions. 

The  Clavicular  Kegion.  —  The  clavicle  can  be  readily  pal- 
pated beneath  the  freely  movable  integument  which  covers  it  from 
its  inner  end,  where  it  articulates  with  the  sternum,  to  its  outer  end, 


174  THORAX. 

where  it  articulates  with  the  acromion  process  of  the  scapula.  The 
acromion  process  of  the  scapula  forms  the  most  external  and  promi- 
nent point  of  the  shoulder. 

Beneath  the  skin  in  the  clavicular  region  are  found  the  platysma 
and  the  deep  fascia. 

To  the  upper  surface  and  posterior  border  of  the  clavicle  are 
attached,  internally,  the  sterno-mastoid  muscle,  and  externally  the 
trapezius.  To  the  inner  half  of  the  front  surface  of  the  clavicle  is 
attached  the  pectoralis  major  muscle  (clavicular  portion),  and,  to 
its  outer  half,  the  deltoid  muscle. 

The  under  surface  of  the  clavicle  shows,  at  its  inner  end,  the 
attachment  of  the  rhomboid  ligament.  This  ligament  extends  be- 
tween the  under  surface  of  the  clavicle  and  the  cartilage  of  the  first 
rib.  External  to  this  the  subclavius  muscle  arises  from  the  under 
surface  of  the  clavicle. 

The  inferior  surface  of  the  outer  end  of  the  clavicle  is  con- 
nected with  the  coracoid  process  of  the  scapula  by  strong  ligamentous 
bands. 

Beneath  the  clavicle,  between  it  and  the  first  rib,  the  blood- 
vessels and  nerves  pass  from  the  root  of  the  neck  into  the  axilla. 

The  Infeaclaviculak  Eegion. — This  is  the  region  below  the 
clavicle.  Between  the  pectoralis  major  and  the  deltoid  muscle,  close 
to  the  clavicle,  there  is  a  triangular  depression,  the  fossa  of  Mohren- 
heim:   the  infraclavicular  fossa. 

In  the  space,  or  groove,  between  the  pectoralis  major  and  the 
deltoid  are  lodged  the  cephalic  vein  and  the  descending  branch  of 
the  acromio-thoracic  artery,  which  is  given  off  from  the  axillary. 
If  the  two  muscles  are  widely  separated,  we  expose  the  upper  part 
of  the  pectoralis  minor,  covered  by  its  fascia,  some  loose  connective 
tissue  and  fat,  and  the  coracoid  process.  This  process  is  readily  felt 
underneath  the  skin,  and  in  thin  persons  can  be  seen. 

If  the  pectoralis  major  is  cut  away  from  its  attachment  to  the 
clavicle  and  from  the  upper  part  of  the  sternum  and  reflected  down- 
ward, the  infraclavicular  region  proper  is  uncovered.  The  pectoralis 
minor  muscle  is  now  more  freely  exposed.  The  cephalic  vein  may 
be  seen  passing  from  without  inward  across  the  pectoralis  minor 
into  a  mass  of  fat  and  connective  tissue  on  the  inner  side  of  the 
muscle,  where  it  disappears  through  an  opening  in  the  costo-coracoid 
membrane  to  reach  the  first  part  of  the  axillary  vein,  which  lies 
underneath  this  membrane. 


REGIONS  OF  THE  CHEST.  175 

The  acromio-thoracic  and  branches  of  the  superior  thoracic 
which  are  derived  from  the  axillary  artery  are  seen  to  emerge  through 
openings  in  the  costo-coracoid  membrane,  as  is  also  the  external 
anterior  thoracic  nerve,  which  supplies  the  pectoralis  major. 

The  costo-coracoid  membrane  is  a  sheet  of  fascia  which  is  con- 
tinued from  the  inner  or  upper  border  of  the  pectoralis  minor  mus- 
cle upward  and  inward,  and  is  attached  to  the  under  surface  of  the 
clavicle  and  to  the  first  rib;  it  covers  in  the  first  part  of  the  axillary 
artery  and  the  structures  that  accompany  it  and  the  subclavius  mus- 
cle. When  the  costo-coracoid  membrane  is  removed,  we  expose  the 
first  part  of  the  axillary  artery  and  its  acromio-thoracic  and  superior 
thoracic  branches,  the  cords  of  the  brachial  plexus,  which  lie  above 
the  artery,  and  the  axillary  vein,  which  lies  below  and  internal  to  the 
artery.  The  cephalic  vein  may  be  seen  passing  across  the  axillary 
artery  to  enter  the  axillary  vein.  All  these  structures  are  gathered 
together  into  a  single  bundle,  and  are  accompanied  by  a  mass  of 
fat,  connective  tissue,  and  lymphatics  (see  Fig.  183). 

The  Mammaey  Eegion  (Beeast).  —  The  mammary  gland  is 
rudimentary  in  the  male  and  naturally  well  developed  in  the  female. 
It  rests  upon  the  pectoralis  major  muscle  from  the  third  to  the  sixth 
rib.  In  unmarried  and  in  young  females  it  is  hemispheroidal,  firm, 
and  projects  forward;  but  after  child-bearing,  and  especially  in  some 
races  more  than  others,  it  is  pendulous,  and  hangs  down  over  the 
lower  part  of  the  thorax. 

The  skin  of  this  region  is  thin  and  fine  and  is  freely  movable 
upon  the  underlying  tissue.  The  superficial  veins  may  show  through 
the  skin  as  irregular  blue  streaks.  The  skin  of  the  nipple  is  espe- 
cially thin  and  pigmented,  and  may  be  fissured  and  split,  and  shows 
the  orifices  of  the  milk-ducts,  fifteen  to  twenty  in  number,  as  very 
fine,  needle-point  openings;  through  these  infection  may  reach  the 
mammary  gland  tissue  proper. 

In  the  unpregnant  the  nipple  is  depressed  and  pinkish,  but  is 
prominent  and  dark  colored  during  pregnancy.  The  nipple  is  sur- 
rounded by  a  pigmented  area,  areola,  which  is  fixed  to  the  under- 
lying tissue  and  marked  by  little  nodules  which  correspond  to  se- 
baceous and  sweat-glands. 

In  the  unmarried  the  mammary  gland  proper  is  small,  the  promi- 
nence of  the  breast  being  due  chiefly  to  the  abundance  of  the  fatty 
tissue  in  which  the  gland  is  imbedded.  It  does  not  reach  its  full 
development  until  after  pregnancy.     The  mammary  gland  is  a  teg- 


176  THORAX. 

mentary  organ  inclosed  within  its  own  proper  fibrous  capsule  and 
lodged  in  the  subcutaneous  fat.  It  consists  of  a  number  of  lobules, 
which  are  separate  and  distinct  from  each  other;  so  that  the  secre- 
tion of  milk  and  nursing  may  be  continued  even  after  one  or  more 
lobules  have  become  the  seat  of  a  suppurative  process.  Between 
the  mammary  gland  and  the  anterior  surface  of  the  pectoralis  major 
muscle  there  is  a  layer  of  loose  fatty  tissue,  which  permits  the  gland 
to  be  freely  moved  about  upon  the  surface  of  the  muscle. 

Occasionally  a  process  of  gland  tissue  almost  entirely  discon- 
nected from  the  main  gland  may  be  found  lying  under  the  border 
of  the  pectoralis  major,  dipping  beneath  the  muscle  into  the  axilla. 
This  process  of  gland  tissue  is  often  difficult  to  recognize.  All  the 
ducts  of  the  gland  converge  from  the  periphery  toward  the  nipple; 
they  may  become  occluded  and  distended,  giving  rise  to  cystic  tumors 
whose  contents  consist  of  milk  or  of  a  buttery  material:   galactocele. 

The  arteries  of  the  breast  consist  of  perforating  branches  from 
the  internal  mammary,  especially  the  second  and  third  and  branches 
of  the  long  thoracic  from  the  axillary.  Of  the  veins,  the  superficial 
ramify  beneath  the  skin  and  the  deep  ones  accompany  the  arteries. 

The  lymphatics  are  important  and  of  these  there  are  two  sets: 
those  of  the  integument  and  those  which  drain  the  gland  proper. 
The  lymphatics  of  the  integument  are  very  superficial  and  numerous, 
especially  upon  the  nipple  and  in  the  areola;  corresponding  to  the 
region  of  the  areola,  they  form  a  fine  capillary  net-work  which 
spreads  outward  toward  the  periphery,  some  branches  dipping  in- 
ward to  enter  a  plexus  which  surrounds  the  milk-ducts  beneath  the 
skin  of  the  areolar  region.  The  lymphatics  from  the  gland  proper, 
from  the  acini  and  substance  of  the  gland,  are  abundant.  Accord- 
ing to  Sappay,  they  all  tend  toward  the  surface  and  end  as  good- 
sized  vessels  in  the  plexus  already  mentioned  which  surrounds  the 
milk-ducts  beneath  the  skin  of  the  areola.  The  lymph  from  this 
subareolar  plexus  is  collected  into  two  main  channels:  one  above 
and  one  below  the  nipple.  These  lymphatic  vessels  pass  outward 
toward  the  outer  border  of  the  gland,  and,  after  being  joined  by  one 
or  two  vessels  from  the  periphery  of  the  gland,  terminate  in  the 
nearest  lymphatic  nodes,  which  are  found  near  the  anterior  wall  of 
the  axilla  in  the  neighborhood  of  the  third  and  fourth  ribs,  being 
covered  usually  by  the  edge  of  the  pectoralis  major.  These  are,  as 
a  rule,  the  first  lymphatic  nodes  to  become  involved  in  disease  of 
the  mammary  gland.     The  lymphatic  nodes  in  the  root  of  the  neck 


MEDIASTINUM  AND  CONTENTS.  177 

also  receive  tributaries  from  the  breast,  and  may  be  found  involved 
when  the  mammary  gland  is  diseased. 

The  Lower  Anterior  Pectoral  Region. — This  is  the  area  which 
lies  between  the  lower  limits  of  the  pectoralis  major  muscle  and 
the  free  border  of  the  ribs.  This  region  is  important  surgically  only 
on  account  of  the  structures  which  lie  beneath  it,  within  the  chest 
and  abdomen. 

The  Lateral  Pectoral  Region. — This  space  is  included  between 
the  border  of  the  pectoralis  major  in  front  and  that  of  the  latissimus 
dorsi  behind.  It  presents  the  ribs  covered  by  serrations  of  the  ser- 
ratus  magnus  and  by  the  latissimus  dorsi  and  obliquus  abdominis 
externus. 

The  arteries  of  this  region  are  derived  from  the  axillary  (long 
thoracic)  and  intercostals.  The  posterior  thoracic  nerve  is  found  in 
this  region  descending  upon  the  serratus  magnus,  which  it  supplies. 

THE  MEDIASTINUM  AND  CONTENTS. 

The  mediastinum  is  a  space  within  the  chest,  between  the  two 
pleural  cavities,  which  is  occupied  by  the  heart  and  pericardium,  the 
thymus  or  its  remains,  the  trachea,  oesophagus,  aorta,  and  several 
nerves,  and  a  mass  of  loose  connective  tissue  and  lymphatics. 

Eather  more  of  the  space  lies  to  the  left  of  the  middle  line 
than  to  the  right.  It  is  limited  in  front  by  the  sternum,  behind  by 
the  vertebral  column,  and  its  floor  is  formed  by  the  diaphragm. 
Above,  the  loose  connective  tissue  of  this  space  is  continuous  into 
the  root  of  the  neck  with  that  which  surrounds  the  oesophagus  and 
trachea  and  the  great  vessels  in  the  neck.  Laterally  the  mediastinum 
is  walled  off  on  either  side  from  the  pleural  cavity  by  the  parietal 
pleura  (mediastinal  portion  of  the  parietal  pleura). 

The  mediastinum,  as  mentioned  above,  is  not  an  empty  space, 
but  is  fairly  closely  occupied  by  various  organs.  In  the  lower  part 
of  this  space,  in  front,  is  the  heart,  inclosed  within  its  pericardial 
sac;  behind  the  heart,  between  it  and  the  vertebral  column,  the 
space  is  not  large,  and  is  occupied  by  the  oesophagus,  thoracic  duct, 
thoracic  aorta,  vena  azygos,  vena  hemiazygos,  and  various  nerves. 
In  the  upper  part  of  the  mediastinum,  in  front,  is  the  thymus  or  its 
remains,  and  behind  this  the  trachea  and  oesophagus,  the  latter  lying 
just  in  front  of  the  vertebral  column.  Immediately  above  the  base 
of  the  heart  are  the  great  vessels  connected  with  the  heart — the  arch 


178 


THORAX. 


of  the  aorta,  vena  cava  superior,  pulmonary  artery  and  its  branches 
— and  the  bifurcation  of  the  trachea.  A  number  of  lymphatic  glands 
which  communicate  with  the  lymphatics  of  the  neck  and  axilla  are 
packed  in  between  these  structures. 

The  Pericardium. — The  heart,  occupying  the  lower  anterior  part 
of  the  mediastinum,  lies  close  to  the  anterior  wall  of  the  chest 
(sternum)  inclosed  within  its  own  serous  sac,  the  pericardium.  The 
pericardium,  as  a  thin  serous  layer,  is  closely  applied  to  the  whole 
surface  of  the  heart  and  to  the  great  vessels  at  its  base  for  a  part  of 


?%f 


!">  Mfc 


Fig.  80. — Transverse  Section  through  Thorax  just  Above  the  Heart  and 
Root  of  the  Lungs.  A,  A,  aorta;  ES,  oesophagus;  LPA,  left  pulmonary  artery; 
MP,  mediastinal  pleura  passing  forward  to  the  posterior  aspect  of  the  root 
of  the  lung;  PA,  pulmonary  artery;  PE,  pericardium;  PN,  phrenic  nerve; 
PP,  parietal  layer  of  pleura;  PS,  space  between  parietal  and  visceral  layers 
of  the  pleura;  RB,  right  bronchus;  RPA,  right  pulmonary  artery;  8,  ster- 
num;  YA,  vena  azygos;  TC,  vena  cava  superior;   VP,  visceral  layer  pleura. 


their  extent;  above,  after  inclosing  the  first  or  ascending  part  of  the 
arch  of  the  aorta,  it  is  reflected  as  a  thin,  loose,  membranous  sac, 
which  completely  envelops  the  heart  and  is  attached  below  by  its 
broad  base  to  the  dome  of  the  diaphragm.  The  highest  limit,  or  the 
apex,  of  the  pericardial  sac  is  that  portion  which  incloses  the  first  part 
of  the  arch  of  the  aorta.  Its  broad  base,  which  is  below,  corresponds 
to  its  attachment  to  the  diaphragm.     The  pulmonary  artery  is  also 


MEDIASTINUM  AND  CONTENTS.  179 

included  within  the  pericardial  sac  as  far  as  its  bifurcation,  but  its 
two  divisions  are  not  included.  The  vena  cava  superior  is  also 
partially  invested. 

In  front,  the  pericardial  sac  is  in  relation  with  the  sternum 
and  the  costal  cartilages,  from  which  it  is  separated  by  the  inter- 
posed pleura  and  the  edges  of  the  lungs.  Behind  the  lower  part  of 
the  sternum  there  is  a  triangular  space — with  its  apex  above  upon  a 
level  with  the  fourth  costal  cartilage,  a  little  to  the  left  of  the 
middle  line,  and  its  base  below,  corresponding  to  the  junction  of  the 
body  of  the  sternum  with  the  ensiform  cartilage:  i.e.,  on  a  level 
with  the  articulation  of  the  sixth  costal  cartilage — where  the  peri- 
cardium lies  in  direct  relation  with  the  posterior  surface  of  the 
sternum.  Corresponding  to  this  area  the  pleura  and  the  edge  of  the 
lung  are  not  interposed  between  the  sternum  and  the  pericardial 
sac.  Occasionally,  according  to  some  descriptions,  the  edge  of  the 
left  pleura  fails  to  reach  the  left  border  of  the  sternum  behind  the 
fifth  costal  cartilage  and  fifth  intercostal  space,  and  under  these 
circumstances  one  could  puncture  through  the  fifth  space  close  to 
the  left  border  of  the  sternum  and  enter  the  pericardial  sac  without 
meeting  the  pleura.  In  all  cases  the  edge  of  the  left  lung  is  notched 
in  this  region,  incisura  cardiaca;  so  that,  although  one  might  en- 
counter the  pleura  in  puncturing  in  this  situation,  he  would  not, 
in  any  case,  meet  the  lung.  Corresponding  to  the  incisura  cardiaca 
is  the  region  of  the  "cardiac  impulse,"  and  here  the  heart  is  most 
exposed.  Behind,  that  part  of  the  pericardial  sac  which  covers  the 
left  auricle  is  in  close  relation  with  the  oesophagus.  The  trachea 
bifurcates  just  above  and  close  to  that  part  of  the  pericardial  sac  that 
covers  the  left  auricle.  On  each  side  the  pericardium  is  firmly  ad- 
herent to  the  mediastinal  portion  of  the  parietal  pleura,  and  between 
the  apposed  layers  of  both  these  structures,  upon  either  side,  the 
phrenic  nerve  descends  in  its  course  to  reach  and  supply  the  dia- 
phragm. 

The  Heart. — The  heart,  inclosed  within  the  pericardial  sac,  is 
located  in  the  lower  anterior  part  of  the  mediastinum,  almost  com- 
pletely surrounded  by  the  lungs,  which  show  a  hollowed-out  cavity 
on  their  internal  surface  corresponding  to  the  size  and  shape  of 
the  heart.  The  impression  upon  the  left  lung  is  deeper  than  that 
upon  the  right. 

Behind  the  heart  is  the  vertebral  column,  and  in  the  space  be- 
tween the  heart  and  the  spinal  column,  in  the  lower  back  part  of 


180  THORAX. 

the  mediastinum,  are  the  oesophagus,  accompanied  by  the  pneumo- 
gastric  nerves;  the  thoracic  aorta  and  thoracic  duct;  the  vena 
azygos,  which  lies  to  the  right  of  the  vertebral  column;  and  the 
vena  hemiazygos,  which  lies  to  the  left  of  the  column. 

The  heart,  with  its  long  axis  directed  downward,  forward,  and 
to  the  left,  rests  with  its  posterior  surface,  which  is  composed  chiefly 
of  the  left  ventricle,  upon  the  central  tendon  of  the  diaphragm. 
Here  the  diaphragm  is  somewhat  flattened,  and  to  the  right  of  the 
middle  line  is  perforated  for  the  passage  of  the  vena  cava  inferior. 
This  vessel,  after  passing  through  the  diaphragm,  enters  almost  im- 
mediately the  lower  contiguous  part  of  the  right  auricle. 

The  anterior  surface  of  the  heart,  composed  mainly  of  the  right 
ventricle  and  auricle,  lies  close  to  the  posterior  surface  of  the  ster- 
num and  costal  cartilages,  from  which  it  is  separated,  for  the  most 
part,  by  the  pleura  and  the  lungs,  these  being  interposed  between 
the  heart  and  the  sternum  and  costal  cartilages. 

The  base  of  the  heart,  which  is  directed  upward  and  backward 
toward  the  spinal  column,  is  made  up  of  the  auricles;  the  right 
auricle  is  placed  anteriorly,  and  receives  above  the  vena  cava  supe- 
rior and  below  the  vena  cava  inferior;  the  left  auricle  forms  the 
posterior  part  of  the  base,  lying  close  to  the  oesophagus,  and  receives 
the  pulmonary  veins  from  either  lung. 

The  apex  of  the  heart,  the  lowest  part  of  the  left  ventricle,  is 
found  in  the  fifth  left  intercostal  space  midway  between  the  para- 
sternal and  mammary  lines. 

Above  the  heart  are  the  arch  of  the  aorta,  with  the  superior 
vena  cava  placed  close  upon  the  right  side  of  its  first  or  ascending 
part,  the  pulmonary  artery  and  its  bifurcation,  the  bifurcation  of 
the  trachea,  and  a  mass  of  lymphatic  glands  and  fat. 

The  Outlines  of  the  Heart  upon  the  Chest  Wall. — The 
lower  border  of  the  heart  corresponds  to  the  line  of  junction  between 
the  body  of  the  sternum  and  its  ensiform  cartilage.  The  upper 
border  of  the  heart  corresponds  to  the  upper  border  of  the  third 
costal  cartilage.  To  the  right  of  the  sternum  lies  the  right  auricle, 
its  boundary  corresponding  to  a  curved  line  which  is  drawn  from  the 
articular  end  of  the  third  costal  cartilage  downward  and  through  the 
fifth  costal  cartilage  close  to  its  articulation  with  the  sternum.  The 
right  ventricle  reaches  over  for  a  considerable  distance  to  the  left 
of  the  sternum,  with  a  portion  of  the  left  ventricle  adjoining  and 
forming  the  left  border  of  the  heart.     The  apex,  the  extreme  end 


MEDIASTINUM  AND  CONTENTS. 


181 


of  the  left  ventricle,  is  situated  in  the  fifth  intercostal  space  midway 
between  the  parasternal  and  the  mammary  lines. 

One-third  of  the  heart  lies  to  the  right  and  two-thirds  to  the 
left  of  the  middle  line. 

The  pulmonary  orifice,  valve,  corresponds  to  a  line  which  is 


Pig.  81. — Outline  of  Heart  and  Location  of  Valves.  A,  aortic  orifice,  left 
semilunar  valve  (dotted  line) ;  P,  orifice  of  pulmonary  artery,  right  semi- 
lunar valve;  T.M.,  line  of  right  and  left  auriculo-ventricular  orifice.  Upper 
part  of  line  corresponds  to  left  auriculo-ventricular  orifice,  mitral  valve. 
Lower  part  of  line  corresponds  to  right  auriculo-ventricular  opening,  tri- 
cuspid valve.  Position  of  the  diaphragm  is  indicated  by  the  curved  line  that 
passes  below  the  inferior  border  of  the  heart. 


placed  upon  the  junction  of  the  third  costal  cartilage  with  the  left 
border  of  the  sternum,  half  of  the  line  upon  the  cartilage  and  half 
upon  the  sternum. 

The  aortic  orifice,  valve,  may  be  indicated  by  a  line  drawn  from 


182  THORAX. 

the  junction  of  the  third  costal  cartilage  with  the  left  border  of  the 
sternum,  just  below  the  line  indicating  the  pulmonary  valve  and 
diverging  from  this,  as  far  as  the  middle  line,  to  a  level  with  the 
third  space. 

The  auriculo-ventricular  openings  are  represented  by  a  line  ex- 
tending from  the  lower  border  of  the  third  left  costal  cartilage,  one 
finger's  breadth  beyond  the  left  border  of  the  sternum,  downward 
and  toward  the  right,  across  the  body  of  the  sternum,  as  far  as  the 
junction  of  the  sixth  right  costal  cartilage  with  the  right  border  of 
the  sternum.  The  lower  part  of  this  line  represents  the  tricuspid 
(right  auriculo-ventricular)  orifice  and  the  upper  part  represents  the 
mitral  (left  auriculo-ventricular)  orifice. 

The  Thymus. — The  thymus  body  in  the  newborn  is  located  in 
the  upper  front  part  of  the  mediastinum  behind  the  sternum  and 
in  front  of  the  upper  part  of  the  pericardial  sac.  Its  upper  portion 
reaches  well  upward,  in  front  of  the  trachea,  into  the  root  of  the 
neck.  In  the  upper  part  of  the  mediastinal  space  the  thymus  lies 
directly  in  front  of  the  trachea,  the  left  innominate  vein,  which 
passes  from  left  to  right,  across  the  front  of  the  trachea,  being  in- 
terposed between  them.  In  the  root  of  the  neck  the  thymus  lies 
upon  the  front  of  the  trachea,  and  is  in  relation,  on  either  side,  with 
the  common  carotid  artery  and  the  internal  jugular  vein. 

The  lower  part  of  the  thymus  lies  behind  the  body  of  the  ster- 
num and  in  front  of  the  great  vessels  at  the  base  of  the  heart,  dip- 
ping down  between  the  pericardial  sac  and  the  edges  of  the  lungs 
and  pleura. 

"The  thymus  increases  in  size  from  birth  until  the  second  year, 
and  then  remains  stationary  or  atrophies  slowly  until  puberty.  After 
puberty  it  atrophies  rapidly,  undergoing  fatty  changes. 

The  Arch  of  the  Aorta.  —  The  arch  of  the  aorta  is  well  sur- 
rounded by  the  lungs,  the  edges  of  which  nearly  meet  behind  the 
sternum. 

It  arises  from  the  left  ventricle,  and  at  its  origin  lies  behind 
the  root  of  the  pulmonary  artery.  It  first  passes  upward,  forward, 
and  toward  the  right  as  far  as  the  right  border  of  the  sternum;  it 
then  turns  backward  and  toward  the  left,  arching  over  the  left  bron- 
chus; and  near  the  upper  border  of  the  body  of  the  fourth  dorsal 
vertebra,  upon  its  left  side,  it  turns  downward  and  is  continued  as 
the  thoracic  aorta. 

The  arch,  as  it  passes  backward  and  to  the  left  over  the  left 


MEDIASTINUM  AND  CONTENTS.  183 

bronchus,  reaches  its  highest  point,  which  is  upon  a  level  with  the 
upper  border  of  the  first  costal  cartilage. 

The  Ascending  Paet  of  the  Aech. — Upon  the  right  side  and 
close  to  the  ascending  or  first  part  of  the  arch  lies  the  superior  vena 
cava,  which  enters  the  upper  part  of  the  right  auricle;  this  part  of 
the  arch  and  the  superior  vena  cava  are  situated  in  front  of  the  root 
of  the  right  lung.  The  vena  azygos,  passing  forward  from  the  right 
side  of  the  vertebral  column,  crosses  the  root  of  the  right  lung  and 
empties  into  the  vena  cava  superior  through  its  posterior  wall. 

The  Teansveese  Paet  of  the  Aech. — The  transverse  part  of 
the  arch  passes  from  right  to  left  and  from  before  backward,  from 
the  right  border  of  the  sternum  to  the  left  side  of  the  body  of  the 
fourth  dorsal  vertebra,  arching  over  the  root  of  the  left  lung.  Its 
upper  border  is  upon  a  leve.  ■•■  th  the  upper  border  of  the  first  costal 
cartilage.  From  the  upper  aspect  of  the  transverse  part  of  the  arch 
are  given  off  the  innominate  and  the  left  common  carotid  and  sub- 
clavian arteries. 

Below  the  transverse  part  of  the  arch  is  the  pulmonary  artery 
and  its  bifurcation,  the  branches  passing  transversely- — -one  to  the 
hilum  of  each  lung — and  lying  in  front  of  the  bronchi.  Behind  the 
transverse  part  of  the  arch,  in  the  back  part  of  the  mediastinum, 
the  trachea  and  the  oesophagus  are  located. 

In  front  of  the  transverse  part  of  the  arch  are  the  sternum, 
the  thymus  or  its  remains,  and  the  edges  of  the  pleura  and  the  edges 
of  the  lungs,  which  nearly  meet  directly  behind  the  sternum.  A 
little  above  and  in  front  of  the  transverse  part  of  the  arch,  passing 
from  left  to  right  across  the  middle  line,  is  the  left  innominate  vein. 
The  left  superior  intercostal  vein  passes  forward  from  the  third  left 
intercostal  space  near  the  spinal  column  and  enters  the  left  innomi- 
nate in  front  of  this  part  of  the  arch.  To  the  left  of  the  middle  line, 
the  left  pneumogastric  nerve  descends  in  front  of  and  close  to  the 
transverse  part  of  the  arch,  and  gives  off  its  recurrent  laryngeal 
branch,  which  curves  around  the  arch  and  ascends  into  the  neck. 
Also  descending  in  front  of  the  transverse  part  of  the  arch,  but 
nearer  the  middle  line  than  the  left  pneumogastric,  is  the  left 
phrenic  nerve. 

The  Pneumogastric  Nerves. — These  pass  through  the  thoracic 
cavity,  in  close  relation  with  the  oesophagus,  on  their  way  to  the 
stomach. 

The  right  pneumogastric,  at  the  root  of  the  neck,  lies  between 


184  THORAX. 

the  common  carotid  artery  and  the  internal  jugular  vein.  It  de- 
scends into  the  chest,  across  the  front  of  the  first  part  of  the  sub- 
clavian artery,  between  it  and  the  subclavian  vein.  Within  the  chest 
it  passes  obliquely  backward,  close  to  the  right  side  of  the  trachea 
and  across  the  posterior  aspect  of  the  root  of  the  right  lung,  where 
it  takes  part  in  the  formation  of  the  posterior  pulmonary  plexus. 
The  nerve  then  approaches  the  middle  line  and  descends  upon  the 
posterior  surface  of  the  oesophagus  and  through  the  oesophageal 
opening  in  the  diaphragm,  to  be  distributed  to  the  posterior  sur- 
face of  the  stomach. 

The  left  pneumogastric  dips  into  the  chest  between  the  left 
carotid  and  subclavian  arteries,  behind  the  left  innominate  vein,  and, 
descending  across  the  front  of  the  left  end  of  the  transverse  part 
of  the  arch  of  the  aorta,  is  continued  downward,  behind  the  root  of 
the  left  lung  and  thence  upon  the  front  surface  of  the  oesophagus 
and  through  the  diaphragm,  to  be  distributed  to  the  anterior  surface 
of  the  stomach. 

The  Inferior  Eeoureent  Branches.  —  Upon  the  right  side 
the  inferior  recurrent  is  given  off  from  the  pneumogastric  as  it 
passes  across  the  front  of  the  first  part  of  the  subclavian  artery. 
Curving  around  this  vessel,  it  ascends  in  the  neck,  in  the  recess  be- 
tween the  oesophagus  and  the  trachea,  to  enter  the  lower  part  of  the 
larynx. 

Upon  the  left  side  the  recurrent  is  given  off  as  the  pneumo- 
gastric passes  across  the  front  of  the  transverse  part  of  the  arch  of 
the  aorta.  It  winds  around  the  lower  border  of  this  part  of  the 
arch  and  ascends  in  the  neck,  having  a  similar  relation  to  the  oesoph- 
agus and  trachea  as  that  of  the  right  side. 

The  Phrenic  Nerves. — In  the  root  of  the  neck  the  phrenic  nerve 
of  either  side  may  be  seen  crossing  the  front  of  the  scalenus  anticus 
tendon  in  a  direction  from  above  downward  and  inward.  After  en- 
tering the  chest  they  pass  down  in  front  of  the  root  of  either  lung; 
the  left,  in  its  course,  passes  across  the  front  of  the  transverse  part 
of  the  arch  of  the  aorta  parallel  with  the  left  pneumogastric,  but 
more  internally,  nearer  the  middle  line;  the  right  passes  down  upon 
the  right  side  of  the  superior  vena  cava.  They  then  descend  between 
the  pericardium  and  the  mediastinal  portion  of  the  pleura  as  far  as 
the  diaphragm,  which  they  supply. 

The  Trachea. — This  is  an  elastic  membranous  tube  which  is  put 
upon  the  stretch  when  the  head  is  extended.     Set  into  its  wall  are 


MEDIASTINUM  AND  CONTENTS.  185 

a  number  of  cartilaginous  plates,  each  forming  part  of  a  circle. 
These  cartilaginous  plates  are  absent  in  the  posterior  part  of  the 
trachea. 

The  trachea  is  the  continuation  of  the  larynx.  It  begins  in 
the  neck  below  the  cricoid  cartilage  at  the  sixth  cervical  vertebra, 
and  in  this  part  of  its  course  lies  quite  superficial.  As  it  passes 
downward  it  gets  to  lie  deeper,  farther  away  from  the  surface.  In 
the  chest,  opposite  the  fifth  dorsal  vertebra,  just  above  the  base  of 
the  heart,  the  trachea  divides  into  the  two  bronchi. 

In  front  of  the  trachea,  in  the  upper  part  of  the  mediastinum, 
are  the  sternum,  the  thymus  or  its  remains,  connective  tissue,  and 
fat.  It  is  crossed  from  left  to  right  and  obliquely  from  above  down- 
ward by  the  left  innominate  vein;  into  this  vein  in  front  of  the 
trachea,  one  on  each  side  of  the  middle  line,  empty  the  inferior  thy- 
roid veins.1  Occasionally  a  large  arterial  branch,  the  thyroidea  ima, 
arises  from  the  upper  aspect  of  the  transverse  part  of  the  arch  of 
the  aorta  and  ascends  upon  the  front  of  the  trachea.  Lower  down, 
the  trachea  is  crossed  by  the  transverse  part  of  the  arch  of  the  aorta 
and  the  vessels  arising  from  the  superior  aspect  of  this  vessel.  The 
innominate  and  left  carotid  arteries,  at  their  origin,  are  placed  in 
front  of  the  trachea.  The  right  pneumogastric,  in  the  upper  part 
of  the  chest,  lies  close  to  the  right  side  of  the  trachea.  The  oesoph- 
agus is  situated  behind  the  trachea.  It  is  intimately  related  to  the 
posterior,  non-cartilaginous  wall  of  the  trachea;  so  that  foreign 
bodies  lodged  in  the  oesophagus  may,  by  pressure  upon  the  posterior 
wall  of  the  trachea,  seriously  narrow  its  lumen  and  produce  symp- 
toms of  strangulation.  In  the  immediate  neighborhood  of  the  bifur- 
cation of  the  trachea  are  twenty  to  thirty  lymphatic  nodes. 

The  (Esophagus.  —  The  oesophagus  is  the  continuation  of  the 
pharynx,  and  consists  of  a  thick  muscular  coat  with  a  mucous  mem- 
brane lining.  The  mucous  membrane  is  connected  with  the  mus- 
cular coat  by  a  very  loose  submucous  connective  tissue. 

When  collapsed,  the  oesophagus  appears  as  a  flat,  transverse 
band,  with  the  mucous  membrane  thrown  into  longitudinal  folds, 
and  upon  cross  section  it  shows  a  stellate  figure. 

The  oesophagus  commences  behind  the  cricoid  cartilage  on  a 
level  with  the  sixth  cervical  vertebra;  it  descends  through  the  neck 
and  thorax,  piercing  the  diaphragm  upon  a  level  with  the  tenth 


1  The  right  inferior  thyroid  often  empties  into  the  right  innominate. 


186  THORAX. 

dorsal  vertebra,  and  terminates  at  the  cardiac  end  of  the  stomach 
upon  a  level  with  the  eleventh  dorsal  vertebra. 

In  the  neck  and  upper  part  of  the  thorax,  as  far  as  the  fourth 
dorsal  vertebra,  the  oesophagus  lies  close  to  the  front  of  the  vertebral 
column,  but  from  this  point  downward  it  gets  to  lie  farther  away, 
and  as  it  passes  through  the  diaphragm  it  is  located  quite  some  dis- 
tance in  front  of  and  to  the  left  of  the  tenth  dorsal  vertebra. 

The  oesophagus,  throughout  its  course,  is  surrounded  by  loose, 
cellular  tissue  by  which  it  is  connected  with  adjoining  structures. 
The  average  length  of  the  oesophagus  is  about  35  cm.,  and  the  dis- 
tance from  the  teeth  to  the  cardiac  orifice  of  the  stomach  is  about 
50  cm.  To  get  the  distance  from  the  mouth  to  the  cardiac  orifice 
of  the  stomach,  in  any  individual  case,  one  may  measure  from  the 
spinous  process  of  the  eleventh  dorsal  vertebra  to  that  of  the  ver- 
tebra prominens,  and  thence  across  the  shoulder  to  the  mouth. 

The  lumen  of  the  oesophagus  is  narrowest  at  its  commencement 
behind  the  cricoid  cartilage,  again  narrow  opposite  the  third  or 
fourth  dorsal  vertebra  and  again  as  it  passes  through  the  diaphragm. 
At  its  narrowest  part  the  caliber  of  the  oesophagus  has  a  diameter 
of  14  mm.,  but  it  is  capable  of  much  distension  beyond  this. 

Eelations  of  the  OEsophagus.  In  the  Neck  the  oesophagus  lies 
upon  the  front  of  the  spinal  column  and  immediately  behind  the 
trachea,  to  the  posterior  non-cartilaginous  wall  of  which  it  is  united 
by  loose  connective  tissue.  The  oesophagus,  situated  behind  the 
trachea,  protrudes  a  considerable  distance  beyond  the  left  border  of 
the  latter,  and  is  therefore  in  closer  relation  with  the  common 
carotid  artery,  internal  jugular  vein,  etc.,  upon  the  left  side  of  the 
neck  than  upon  the  right  side.  In  the  recess  between  the  trachea 
in  front  and  the  oesophagus  behind,  upon  either  side,  the  recurrent 
laryngeal  nerve  ascends  to  enter  the  lower  part  of  the  larynx.  Above, 
where  the  lateral  lobes  of  the  thyroid  gland  rest  upon  the  sides  of 
the  trachea,  they  reach  backward  so  as  to  get  into  close  proximity 
with  the  oesophagus. 

Within  the  Chest. — In  the  upper  part  of  the  chest  the  oesophagus 
is  still  situated  in  front  of  the  spinal  column  close  behind  the  trachea, 
protruding  somewhat  beyond  the  left  border  of  the  latter.  Opposite 
the  third  dorsal  vertebra  it  is  placed,  together  with  the  trachea,  be- 
hind the  transverse  part  of  the  arch  of  the  aorta.  Opposite  the 
fourth  dorsal  vertebra  the  descending  part  of  the  arch  of  the  aorta 
lies  to  the  left  side  of  the  oesophagus,  pushing  it  (the  oesophagus)  a 


MEDIASTINUM  AND  CONTENTS.  187 

little  over  toward  the  right;  but  immediately  below  this  the  azygos 
vein,  appearing  upon  the  right  side  of  the  oesophagus,  forces  it  again 
to  the  left,  and  here  at  this  level  the  oesophagus  is  found  behind  the 
root  of  the  left  lung,  to  which  it  is  loosely  attached  by  connective 
tissue.  As  the  oesophagus  descends  it  remains  in  close  relation  with 
the  aorta,  which  vessel  gradually  passes  behind  it  in  order  to  reach 
the  middle  line  in  front  of  the  vertebral  column.  Opposite  the  eighth 
dorsal  vertebra  the  oesophagus  lies  in  front  of  the  aorta,  and  opposite 
the  tenth,  as  it  pierces  the  diaphragm  to  terminate  in  the  stomach, 
it  lies  in  front  and  to  the  left  of  the  aorta  and  spinal  column. 

In  the  space  behind  the  heart,  between  it  and  the  vertebral 
column,  in  the  lower  back  part  of  the  mediastinum,  the  oesophagus 
lies  in  close  proximity,  anteriorly,  with  the  left  auricle,  which  is 
enveloped  in  the  pericardial  sac.  In  this  space,  upon  the  right  side 
of  the  vertebral  column,  is  the  azygos  vein;  upon  the  left,  the 
hemiazygos;  and  in  front  of  the  vertebral  column,  the  thoracic  duct; 
the  aorta  is  situated  behind  the  oesophagus.  The  mediastinal  portion 
of  the  pleura,  as  it  passes  forward  to  the  root  of  the  lung,  is  reflected 
upon  either  side  of  the  oesophagus.  Descending  upon  the  anterior 
wall  of  the  oesophagus  is  the  left  pneumogastric,  and,  upon  its  poste- 
rior wall,  the  right  pneumogastric  nerve.  These  nerves  accompany 
the  oesophagus  through  the  oesophageal  opening  in  the  diaphragm 
and  are  distributed  to  the  stomach. 

The  Thoracic  Aorta. — This  is  the  continuation  of  the  arch.  It 
lies  at  first  upon  the  left  side  of  the  bodies  of  vertebra?,  but  as  it 
descends  it  approaches  the  middle  line,  and  finally,  as  it  passes  into 
the  abdomen  behind  the  diaphragm,  it  lies  in  front  of  the  body  of 
the  last  dorsal  vertebra.  Throughout  its  course  the  thoracic  aorta 
is  closely  related  to  the  oesophagus;  at  first  it  lies  to  the  left  side 
of  the  oesophagus,  but  as  it  descends  it  gets  behind  it,  between  it  and 
the  vertebral  column;  below,  the  oesophagus  is  placed  in  front  of 
and  to  the  left  of  the  aorta,  the  latter  (aorta)  as  it  passes  into  the 
abdomen  being  situated  upon  the  front  of  the  spinal  column.  The 
thoracic  aorta  gives  off  the  intercostal  branches:  one  for  each  inter- 
costal space  from  the  third  downward. 

The  Vena  Azygos.- — This  vein  ascends  upon  the  right  side  of  the 
spinal  column;  it  is  made  up  of  branches  from  the  lumbar  region 
and  receives  the  intercostals  in  its  course.  About  the  level  of  the 
fourth  dorsal  vertebra  it  passes  forward  over  the  root  of  the  right 
lung,  and  enters  the  vena  cava  superior  through  its  posterior  wall. 


188  THORAX. 

The  Vena  Hemiazygos. — The  origin  and  course  of  this  vessel 
are  analogous  to  those  of  the  azygos.  It  ascends  upon  the  left  side 
of  the  vertebral  column.  Opposite  the  eighth  dorsal  vertebra  it 
passes  across  the  front  of  the  spinal  column  behind  the  aorta  and 
thoracic  duct,  and  upon  the  right  side  of  the  vertebral  column  joins 
the  vena  azygos. 

The  Thoracic  Duct  passes  into  the  thorax  behind  the  diaphragm 
in  company  with  the  aorta,  between  this  vessel  and  the  front  of  the 
spinal  column.  As  it  ascends  through  the  thorax  it  lies  upon  the 
bodies  of  the  dorsal  vertebraa.  In  the  upper  part  of  the  chest  it 
arches  forward  and  outward  toward  the  left,  and,  passing  over  the 
subclavian  artery  and  across  the  front  of  the  tendon  of  the  scalenus 
anticus,  it  enters  the  left  subclavian  vein  where  this  vessel  joins  the 
left  internal  jugular. 

The  Innominate  Artery  has  a  caliber  corresponding  to  the  thick- 
ness of  the  little  finger.  It  springs  from  the  right  end  of  the  upper 
border  of  the  transverse  part  of  the  arch  of  the  aorta,  and  is  about 
5  cm.  long.  At  its  origin  it  lies  in  front  of  the  trachea;  it  terminates 
by  dividing  into  the  subclavian  and  common  carotid  behind  the 
right  sterno-clavicular  joint. 

Situated  in  front  of  this  vessel  are  the  sternal  attachments  of 
the  sterno-hyoid  and  sterno-thyroid  muscles,  the  manubrium  of  the 
sternum,  and  the  remains  of  the  thymus  gland.  The  left  innominate 
vein  passes  across  the  front  of  the  root  of  the  innominate  artery,  and 
upon  its  outer  (right)  side  joins  with  the  right  innominate  vein  to 
form  the  vena  cava  superior.  The  right  inferior  thyroid  vein,  as  it 
descends  from  the  lower  part  of  the  thyroid  gland  to  enter  the  right 
innominate  vein,  also  passes  across  the  front  of  the  innominate 
artery.  To  the  outer  side  of  the  innominate  artery  lie  the  right  pneu- 
mogastric  and  the  right  phrenic  nerves  and  the  pleura  and  apex  of 
the  right  lung.  To  the  inner  side  of  the  innominate  is  the  left 
common  carotid,  the  distance  between  the  two  vessels  varying. 

The  Left  Common  Carotid  and  Left  Subclavian  Arteries  arise 
from  the  upper  border  of  the  transverse  part  of  the  arch.  They  lie 
deep  within  the  chest,  and  are,  in  this  region,  not  subject  to  surgical 
interference. 

THE  PLEURA. 

The  pleura  of  each  side  is  a  completely  closed  fibro-serous  sac. 
It  lines  the  entire  inner  surface  of  the  cavity,  within  which  the  lung 


PLEURA.  189 

is  contained,  and,  besides,  as  a  thin,  serous  layer,  invests  the  whole 
surface  of  the  lung. 

That 'portion  of  the  pleura  which  is  applied  to  the  surface  of 
the  lung  is  called  the  visceral  layer,  and  that  which  lines  the  whole 
inner  surface  of  the  cavity  in  which  the  lung  is  contained  is  called 
the  parietal  layer.  That  part  of  the  parietal  pleura  which  lines  the 
inner  surface  of  the  wall  of  the  chest,  sternum,  costal  cartilage,  ribs, 
etc.,  is  spoken  of  as  the  pleura  sterno-costalis;  that  portion  which 
is  spread  out  upon  the  surface  of  the  diaphragm,  the  pleura  dia- 
phragmatica;  and  that  which  limits  the  mediastinum  on  each  side, 
passing  from  before  backward  like  a  partition  and  separating  the 
mediastinal  space  from  the  space  which  contains  the  lung,  is  called 
the  pleura  mediastinalis. 

The  parietal  layer,  after  lining  the  inner  surface  of  the  ribs, 
intercostal  muscles,  etc., — that  is,  the  whole  inner  aspect  of  the 
wall  of  the  thorax, — is  found,  behind,  upon  either  side  of  the  verte- 
bral column,  to  leave  the  posterior  wall  of  the  thorax  and  pass 
forward,  forming  the  posterior  part  of  the  mediastinal  pleura;  that 
of  the  left  side,  as  it  passes  forward,  covers  the  adjacent  wall  of 
the  aorta  and,  lower  down,  the  oesophagus;  that  of  the  right  side, 
as  it  passes  forward,  covers,  below,  the  side  of  the  vena  azygos  and, 
higher  up,  the  side  of  the  oesophagus.  Upon  reaching  the  posterior 
aspect  of  the  root  of  the  lung  the  pleura  is  reflected  on  to  the  sur- 
face of  the  lung  and  as  the  visceral  layer  completely  invests  it,  being 
also  continued  in  between  the  lobes  and  intimately  united  with  its 
surface;  after  thus  entirely  enveloping  the  lung  it  reaches  the  ante- 
rior aspect  of  the  root  of  the  lung,  whence  it  is  reflected  forward 
toward  the  sternum  as  the  anterior  portion  of  the  mediastinal  pleura; 
upon  reaching  the  posterior  surface  of  the  sternum  it  becomes  con- 
tinuous with  that  part  of  the  parietal  pleura  which  lines  the  inner 
surface  of  the  wall  of  the  chest:  the  pleura  sterno-costalis.  Above 
and  below  the  level  of  the  root  of  the  lung  the  mediastinal  pleura 
passes  all  the  way  as  an  uninterrupted  layer  from  behind  forward, 
from  either  side  of  the  spinal  column  to  the  posterior  surface  of  the 
sternum. 

Limits  of  the  Pleura  as  Indicated  by  Lines  upon  the  Chest  Wall. 
The  Anterior  Edge  or  the  Pleura. — The  line  which  indicates 
the  anterior  edge  of  the  right  pleural  sac  commences,  above,  behind 
the  right  sterno-clavicular  articulation;  from  this  point  it  passes 
downward  and  inward  behind  the  sternum,  and  at  the  junction  of 


190  THORAX. 

the  manubrium  with  the  hody  of  the  sternum  it  lies  close  to  the 
middle  line;  it  is  then  continued  downward  behind  the  middle  of 
the  body  of  the  sternum,  and  opposite  the  articulation  of  the  fourth 
costal  cartilage  it  curves  outward,  as  it  descends,  to  reach  a  point 
corresponding  to  the  lower  border  of  the  sternal  end  of  the  sixth 
costal  cartilage,  whence  it  may  be  traced  farther  downward  and 
backward  as  the  lower  edge  of  the  pleura. 

The  line  which  marks  the  anterior  edge  of  the  left  pleural  sac 
is  somewhat  different.  It  commences  above,  behind  the  left  sterno- 
clavicular articulation,  from  which  point  it  curves  downward  and 
inward  toward  the  middle  line  and  may  then  be  traced  downward 
behind  the  body  of  the  sternum  parallel  with  the  anterior  edge  of 
the  right  pleural  sac  to  a  point  upon  a  level  with  the  junction  of  the 
fourth  costal  cartilage  with  the  sternum;  here  it  curves  outward, 
but  more  obliquely  than  upon  the  right  side,  and  reaches  the  sternal 
end  of  the  sixth  costal  cartilage  at  its  upper  border,  whence  it  is  con- 
tinued obliquely  downward  and  backward  as  the  lower  edge  of  the 
pleura. 

According  to  Merkel,  the  anterior  edge  of  the  left  pleural  sac, 
upon  a  level  with  the  fourth  costal  cartilage,  passes  still  more 
obliquely  outward  than  has  been  described  above  so  as  to  strike  the 
sixth  costal  cartilage,  not  at  its  junction  with  the  sternum,  but  some 
little  distance  beyond  this  articulation,  thus  leaving  a  space  between 
the  anterior  edge  of  the  left  pleural  sac  and  the  left  border  of  the 
sternum,  corresponding  to  the  fifth  costal  cartilage,  fifth  intercostal 
space,  and  sixth  costal  cartilage,  which  is  not  covered  by  the  pleura. 
If  this  condition  were  present,  one  might  introduce  an  aspirating 
needle  into  the  pericardial  sac  through  the  fifth  intercostal  space, 
close  to  the  left  border  of  the  sternum,  without  encountering  the 
pleura. 

Without  doubt  the  anterior  edge  of  the  left  pleural  sac  is  sub- 
ject to  considerable  variation.  I  have  found  the  first  description  to 
hold  for  most  cases. 

The  Lower  Edge  of  the  Pleura  corresponds  to  a  line  that 
commences,  in  front,  behind  the  junction  of  the  sixth  costal  carti- 
lage with  the  sternum;  it  passes  downward  and  backward,  crossing 
obliquely  the  cartilage  of  the  seventh  rib  in  the  parasternal  line  and 
passing  into  the  seventh  intercostal  space  in  the  mammary  line;  still 
continued  downward  and  backward  it  reaches  its  deepest  point,  cor- 
responding to  the  tenth  rib  or  tenth  intercostal  space,  a  little  behind 


Fig-.  82.— Outline  of  Pleura,  etc.  Front  view.  A,  apex  of  lung  and  dome  of  pleura; 
A  line  of  diaphragm;  H,  outline  of  heart;  L,  solid  lines  show  the  edges  of  the  lungs; 
P,  dotted  lines  correspond  to  the  edges  of  the  pleura. 


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PLEURA. 


191 


the  axillary  line,  whence  it  may  be  traced  almost  horizontally  back- 
ward and  inward  to  the  articulation  of  the  twelfth  rib  with  the 
spinal  column.  Behind,  in  the  scapular  line,  the  lower  edge  of  the 
pleura  corresponds  to  the  tenth  intercostal  space. 

It  will  be  observed  that  the  lower  edge  of  the  pleura,  as  it  is 
reflected  from  the  inner  surface  of  the  chest  wall  over  on  to  the 
surface  of  the  diaphragm,  does  not  dip  down  into  the  bottom  of  the 
recess  between  the  costal  portion  of  the  diaphragm  and  the  ribs. 
This  space  varies  in  depth  at  different  parts.    Occasionally  the  lower 


Fig.  85. — Section  through  Seventh,  Eighth,  and  Ninth  Ribs  Anterior  to 
the  Axillary  Line.  D,  diaphragm;  EX,  external  intercostal  muscle;  IN,  in- 
ternal intercostal  muscle;  P,  pleura  covering  inner  aspect  of  the  chest  wall; 
PD,  pleura  that  covers  the  diaphragm;  PE,  peritoneum  that  is  reflected  upon 
the  under  surface  of  the  diaphragm;  VAN,  intercostal  vein,  artery,  and  nerve 
situated  under  lower  border  of  the  ribs;  1,  8,  9,  cut  surface  of  ribs;  *  repre- 
sents the  space  between  the  diaphragm  and  chest  wall  into  which  the  pleura 
does  not  descend,  as  it  is  reflected  from  the  chest  wall  on  to  the  upper  sur- 
face of  the  diaphragm. 

edge  of  the  pleura,  behind,  reaches  down  between  the  twelfth  rib  and 
the  diaphragm  as  far  as  the  lower  border  of  the  twelfth  rib,  or,  even 
beyond  this,  down  to  the  level  of  the  transverse  process  of  the  first 
lumbar  vertebra. 

The  Dome  of  the  pleura  is  that  part  of  the  pleural  sac  which 
projects  upward  into  the  root  of  the  neck  above  the  level  of  the  first 
rib;  it  reaches  to  a  distance  of  5  cm.  above  the  level  of  the  anterior 
part  of  the  first  rib,  but  does  not  reach  above  the  level  of  the  back 
part  of  the  first  rib;  the  first  rib  is  set  very  obliquely,  its  anterior 
portion  being  upon  a  much  lower  level  than  its  posterior  part. 


192  THORAX. 

The  dome  of  the  pleura  reaches  from  2  to  4  cm.  above  the  level 
of  the  clavicle;  so  that  a  knife  introduced  above  this  bone  and  passed 
directly  backward  would  pierce  both  the  pleura  and  the  lung.  In 
front  of  the  dome  is  the  first  rib  and  the  posterior  surface  of  the 
scalenus  anticus  muscle  and  the  clavicle.  Internal  to  the  dome  are 
the  trachea  and  the  oesophagus. 

The  subclavian  vessels  pass  forward  and  outward  across  the 
dome,  grooving  it  and  the  apex  of  the  lung,  which  lies  beneath.  Care 
is  necessary  in  ligating  the  subclavian  or  innominate  arteries  not  to 
wound  the  pleura. 

As  the  internal  mammary  artery  dips  down  into  the  chest  it  is 
crossed  by  the  phrenic  nerve  and  lies  in  close  relation  with  the  dome 
of  the  pleura. 

The  dome  of  the  pleura  is  re-enforced  by  the  fascia  endotho- 
racica,  and  connected  behind,  through  ligamentous  bands,  with  the 
first  rib  and  the  last  cervical  and  the  first  dorsal  vertebras  and  in 
front  with  the  deep  surface  of  the  scaleni  muscles. 

The  mediastinal  portion  of  the  pleura  and  the  pericardium  are 
adherent  to  each  other,  and  between  these  two  serous  layers  the 
phrenic  nerves  descend  to  the  diaphragm. 


THE  LUNGS. 

The  Root,  or  Pedicle,  of  the  Lung. — The  root  of  the  lung  is 
located  in  the  back  part  of  the  mediastinum  behind  the  ascending 
part  of  the  arch  of  the  aorta  and  above  the  base  of  the  heart.  That 
of  each  lung  is  composed  of  the  bronchus,  the  pulmonary  artery,  and 
the  pulmonary  veins,  together  with  lymphatics  (also  blood-vessels  for 
the  supply  of  lung  tissue  proper  and  plexuses  of  nerves). 

The  trachea  bifurcates  opposite  the  fifth  dorsal  vertebra,  and 
its  divisions,  the  bronchi,  are  directed  outward  and  downward  toward 
the  hilum  of  either  lung.  The  right  bronchus  is  more  horizontal, 
shorter,  and  of  wider  caliber  than  the  left,  and  its  lumen  is  more 
directly  continuous  with  that  of  the  trachea;  so  that  foreign  bodies 
dropped  into  the  trachea  are  more  apt  to  enter  the  right  than  the 
left'bronchus. 

The  pulmonary  artery  springs  from  the  upper  part  of  the  right 
ventricle,  and  at  its  origin  lies  in  front  of  the  root  of  the  aorta.  It  is 
a  short  trunk,  directed  upward  and  backward,  and  under  the  trans- 


LUNGS.  193 

verse  part  of  the  arch  of  the  aorta  divides  into  the  right  and  left 
pulmonary..  These  pass  outward,  in  front  of  the  bronchi,  to  the  hilum 
of  either  lung.  At  the  hilum  the  pulmonary  arteries  are  located  upon 
a  higher  level  than  the  bronchi,  and  may  get  to  lie  partly  behind 
these  as  they  enter  the  lung. 

The  pulmonary  veins  are  short  trunks  which,  upon  leaving  the 
hilum  of  the  lung,  pass  transversely  inward  and  enter  the  correspond- 
ing side  of  the  left  auricle;  they  lie  some  little  distance  below  the 
level  of  the  bronchi  and  the  pulmonary  arteries. 

There  are  numerous  lymph  nodes  irregularly  arranged  about 
the  root  of  the  lung,  but  there  is  always  a  well-marked  group  below 
the  bifurcation  of  the  trachea. 

Over  the  root  of  the  left  lung,  arching  from  before  backward, 
is  the  arch  of  the  aorta.  The  vena  azygos  passes  over  the  root  of 
the  right  lung,  from  behind  forward,  and  enters  the  vena  cava  supe- 
rior, which  lies  just  in  front  of  the  root  of  the  right  lung,  upon  its 
posterior  aspect. 

The  Lung,  suspended  by  its  root,  occupies  the  pleural  cavity 
and  is  entirely  enveloped  by  the  visceral  layer  of  the  pleura.  At  the 
root  of  the  lung  this  visceral  layer  of  the  pleura  is  continuous  with 
the  mediastinal  part  of  the  parietal  pleura.  The  base  of  the  lung 
rests  upon  the  diaphragm;  its  apex  projects  into  the  root  of  the 
neck  for  a  distance  of  4  or  5  cm.  above  the  front  end  of  the  first 
rib.  In  the  natural  sitting  position  the  apex  of  the  lung  reaches  to 
a  point  about  3  cm.  above  the  clavicle. 

The  right  lung  consists  of  three  lobes,  the  left  of  two.  Each 
lung  upon  its  inner  surface  shows  a  depression  corresponding  to  the 
heart,  that  upon  the  left  lung  being  deeper  than  that  upon  the  right 
lung. 

The  lung  does  not  entirely  fill  the  pleural  cavity  except  above, 
where  the  apex  occupies  all  the  space  corresponding  to  the  dome  of 
the  pleura. 

Limits  of  the  Lungs. — The  posterior  border  of  each  lung  is 
found  alongside  the  vertebral  column.  The  anterior  border  of  the 
lung  corresponds  to  the  line  of  the  pleura  from  the  sterno-clavicular 
articulation  to  the  level  of  the  fourth  costal  cartilage.  The  anterior 
border  of  the  right  lung  continues  to  be  the  same  as  that  of  the  pleura 
down  to  the  level  of  the  sixth  costal  cartilage.  The  anterior  border 
of  the  left  lung,  at  the  junction  of  the  fourth  costal  cartilage  with 
the  sternum,  passes  almost  transversely  outward  behind  the  cartilage 


194  THORAX. 

of  the  fourth  rib,  forming  the  upper  border  of  the  incisura  cardiaca, 
and  then,  midway  between  the  border  of  the  sternum  and  the  nipple, 
it  turns  downward  behind  the  fourth  intercostal  space  and  fifth  costal 
cartilage,  and  in  the  fifth  space  passes  sharply  inward,  forming  the 
lower  border  of  the  incisura  cardiaca. 

The  lower  border  of  either  lung  is  represented  by  a  line  which 
commences  at  the  junction  of  the  sixth  costal  cartilage  with  the 
sternum;  it  passes  downward  and  backward,  behind  the  sixth  costal 
cartilage,  and  crosses  the  seventh  rib  in  the  mammary  line;  from 
this  point  the  line  passes  backward,  almost  transversely,  crossing  the 
eighth  and  ninth  ribs  in  the  axillary  line,  the  tenth  rib  in  the  scap- 
ular line,  and  reaches  the  vertebral  column  upon  a  level  with  the 
articulation  of  the  eleventh  rib.  Although  the  line,  after  crossing 
the  seventh  rib  in  the  mammary  line,  is  continued  almost  trans- 
versely backward,  it  cuts  the  eighth,  ninth,  and  succeeding  lower 
ribs,  owing  to  tbe  obliquity  of  the  ribs. 

The  lower  edge  of  the  lung  does  not  reach  to  the  bottom  of 
the  pleural  cavity;  so  that  a  space  is  left  which  is  called  the  sinus 
phrenico-costalis.  This  space  commences  in  front,  and  gradually 
becomes  deeper;  upon  the  sides  it  is  deepest,  and  may  measure  up 
to  two  inches.  In  more  forcible  inspiration  this  space  is  partly 
obliterated  by  the  increased  expansion  of  the  lung. 

A  similar  pleural  space,  unoccupied  by  the  lung  (incisura  car- 
diaca), is  found  in  front  of  the  pericardium  and  heart,  corresponding 
to  the  fourth  intercostal  space  and  fifth  costal  cartilage,  to  the  left 
of  the  sternum. 

In  the  child  the  distance  between  the  lower  border  of  the  lung 
and  the  bottom  of  the  pleural  cavity  is  one-half  to  one  space  deeper 
than  described  above.  In  old  age  the  distance  between  the  lower 
border  of  the  lung  and  the  bottom  of  the  pleural  cavity  becomes 
one-half  to  one  space  shorter. 

Luschka  gives  the  depth  of  the  sinus  phrenico-costalis  as  fol- 
lows: In  the  sternal,  parasternal,  and  mammary  lines,  2  cm.;  in  the 
axillary  line,  6  cm.;   and  near  the  vertebra,  2.5  cm. 

OPERATIONS  UPON  THE  CHEST. 

Incisions  for  Abscess  of  the  Breast. — These  should  radiate  from 
the  region  of  the  nipple  toward  the  periphery  of  the  breast  in  order 
to  avoid,  as  far  as  possible,  cutting  across  the  milk-ducts,  which  all 


OPERATIONS  UPON  THE  CHEST.  195 

converge  toward  the  nipple.  The  incisions  should  he  liberal,  and 
should  he  so  placed  as  to  allow  the  discharge  to  drain  through  the 
lower,  dependent  part  of  the  breast,  and,  if  necessary  in  order  to 
accomplish  this,  one  or  more  counter-openings  may  be  made.  Liberal 
incisions  should  be  made  through  the  skin  and  fat,  and  the  abscess 
cavity  penetrated  with  closed  artery  forceps,  which  are  spread  apart 
as  they  are  withdrawn. 

Extirpation  of  Tumors  Out  of  the  Substance  of  the  Mammary 
Gland  (Fibroids,  for  Example). — An  incision  is  made  corresponding 
in  length  to  the  size  of  the  tumor  and  radiating  from  the  areola 
toward  the  periphery  of  the  breast. 

These  tumors  are  usually  encapsulated  and  well  defined,  and 
can  be  dissected  out  with  blunt-pointed  scissors  or  may  at  times  be 
enucleated  by  blunt  dissection  with  the  finger. 

Amputation  of  the  Breast. — The  patient  lies  upon  the  back  with 
the  arm  abducted.  The  incision  depends  upon  the  size  of  the  tumor 
and  the  condition  of  the  skin.  If  the  skin  is  involved  in  the  patho- 
logical process,  the  diseased  portion  should  be  sterilized  and  packed 
or  covered  with  gauze,  and  the  incision  placed  at  least  two  inches 
outside  of  the  affected  area  of  the  skin. 

The  incision  should  be  so  arranged  that  the  edges  of  the  wound 
may  be  brought  together  with  sutures,  after  the  breast  has  been 
removed,  for  the  purpose  of  obtaining  primary  union;  yet  one  should 
not  hesitate  to  sacrifice  all  suspicious  integument,  since  any  defect 
that  remains  may  be  covered  by  skin  grafting. 

The  usual  incision  is  one  which  includes  an  elliptical  area  of  the 
skin  and  the  nipple,  set  obliquely  so  as  to  run  parallel  with  the  fibers 
of  the  pectoralis  major,  the  upper  end  of  the  ellipse  being  continued 
along  the  border  of  the  pectoralis  major  into  the  upper  arm  in  order 
to  empty  the  axilla.  The  edge  of  the  skin,  on  the  inner  side  of  the 
ellipse,  is  seized  with  the  fingers  or  a  thumb  forceps,  and,  including 
little  or  none  of  the  subcutaneous  fat,  is  separated  from  the  under- 
lying tumor  and  breast  beyond  its  farthest  limits  and  down  to  and 
exposing  the  surface  of  the  pectoralis  major  muscle. 

If  the  breast  (tumor)  is  not  adherent  to  the  pectoralis  major  it 
may  be  readily  detached  from  the  surface  of  this  muscle  with  the 
fingers,  and  then,  after  separating  the  skin  which  covers  the  outer 
part  of  the  breast  it  may  be  turned  out  of  the  wound  ;  as  the  fascia, 
however,  which  covers  the  pectoralis  major  is  often  involved  in  the 
disease  even  when  apparently  healthy  (Volkmann),  it  is  better,  in 


196  THORAX. 

all  cases,  to  remove  this  fascia,  together  with  the  superficial  portion 
of  the  muscle,  along  with  the  breast,  all  in  one  mass. 

At  times,  portions  of  the  mammary  gland,  partially  disconnected 
from  the  main  mass  of  the  gland  and  lying  in  the  adjacent  fat,  are 
difficult  to  recognize,  or  the  gland  itself  may  be  flattened  out  and 
difficult  to  identify,  or  a  portion  of  the  gland,  almost  completely 
detached  from  the  main  gland,  may  be  found  externally  under  the 
outer  border  of  the  pectoralis  major.  Care  must  be  exercised  to 
include  all  these  parts,  and  this  can  only  be  accomplished  by  ex- 
cising the  entire  gland  and  the  fat  in  which  it  is  imbedded,  together 
with  the  fascia  which  covers  the  pectoralis  major  and  the  superficial 
portion  of  this  muscle  and  the  contents  of  the  axilla,  all  in  one  mass. 

If  the  muscle  is  deeply  involved,  the  whole  muscle  down  to  the 
ribs  should  be  sacrificed,  and  it  may  even  be  necessary,  at  times,  to 
remove  the  surface  of  the  ribs;  but  these  are  rather  hopeless  cases 
at  best. 

After  the  breast  (tumor)  has  been  entirely  freed  from  the  skin 
and  pectoralis  muscle,  but  not  yet  detached,  cut  away,  at  its  axillary 
end,  the  axilla  is  opened  and  its  entire  contents — glands,  connective 
tissue,  fat,  etc. — excised  in  one  mass,  which  still  remains  continuous 
with  the  breast  (tumor). 

In  this  way  the  whole  axillary  space  is  completely  cleaned  out, 
working  close  along  the  course  of  the  axillary  vessels  and  adjoining 
nerves  and  ligating  all  vascular  branches  as  they  are  encountered. 
The  glands  that  are  involved  often  extend  high  up  into  the  axilla 
under  the  clavicle,  and  there  may  be  some  difficulty  in  removing 
these. 

The  axillary  vein  should  be  exposed  early  during  this  part  of 
the  operation.  It  rests  upon  the  tendon  of  the  latissimus  dorsi, 
which  is  the  guide  to  the  vessel,  below  and  to  the  inner  side  of  the 
axillary  artery.  The  axillary  vessels  are  accompanied  by  large  nerve 
trunks  and,  these,  together  with  the  vessels,  are  located,  all  in  a 
bunch,  close  to  the  humerus,  resting  upon  the  tendon  of  the  latis- 
simus dorsi,  beneath  the  edge  of  the  coraco-brachialis  and  the  short 
head  of  the  biceps.  If  the  vessels  are  thus  sought  for  and  exposed 
early  in  the  operation  they  are  less  liable  to  be  accidentally  injured. 
It  is  also  necessary  to  clean  out  the  space  between  the  pectoralis 
major  and  the  pectoralis  minor  muscles. 

If  the  mass  already  involves  the  axillary  vessels  and  nerves,  and 
this  is  usually  indicated  by  shooting  pains  in  the  arm  and  oedema 


OPERATIONS  UPON  THE  CHEST.  197 

of  the  arm,  the  case  is,  at  best,  rather  hopeless,  and  it  is  questionable 
whether  the  .operation  had  not  better  be  left  undone. 

In  clearing  out  the  axilla  some  large  arteries  and  veins  may  be 
severed,  but  these  may  be  clamped  and  ligated;  they  may  be  often 
seen  before  they  are  cut,  and  can  then  be  tied  before  they  are  divided, 
or  they  may  be  avoided. 

The  long  thoracic  nerve,  which  supplies  the  serratus  magnus, 
lies  upon  the  side  of  the  chest,  in  the  posterior  part  of  the  axillary 
space;  it  is  usually  seen  and  may  be  avoided,  although  it  is  of  but 
little  consequence  if  it  is  accidentally  divided.  One  should  also,  if 
possible,  avoid  the  long  subscapular  nerve  which  runs  in  company 
with  the  subscapular  vessels  upon  the  posterior  wall  of  the  axilla. 

If  the  clearing  out  of  the  axilla  is  commenced  below,  close  to 
the  under  border  of  the  pectoralis  major,  the  long  thoracic  artery 
and  vein  and  long  thoracic  nerve  are  encountered  early,  and  they 
may  be  avoided  or  used  as  guides  in  seeking  the  axillary  vein. 

During  the  operation  the  parts  must  be  well  retracted,  and,  in 
order  to  minimize  the  loss  of  blood  as  much  as  possible,  each  vessel 
should  be  clamped  as  it  is  cut,  and  that  part  of  the  wound  which  is 
not  under  immediate  consideration  compressed  with  hot  pads  to 
prevent  oozing.  The  bleeding  should  be  entirely  controlled  before 
the  wound  is  finally  closed. 

With  interrupted  sutures  the  edges  of  the  wound  are  coapted 
as  far  as  possible,  and  the  area  which  is  then  still  left  uncovered 
may  be  provided  with  skin  grafts.  It  is  wise  to  place  a  tube  in  the 
axilla  for  the  purpose  of  drainage. 

Amputation  of  the  Breast  (Halsted-Meyer) .  —  The  breast,  to- 
gether with  the  pectoralis  major  and  minor  muscles  and  the  glands 
and  connective  tissue  of  the  axilla,  must  all  be  removed  in  one  single 
mass  and  without  cutting  into  the  diseased  tissue. 

An  incision  is  made  through  the  healthy  skin  and  fat,  elliptical 
and  circumscribing  the  tumor;  from  the  upper  end  of  the  ellipse 
the  incision  should  be  continued  along  the  edge  of  the  pectoralis 
major  to  a  point  upon  the  iipper  part  of  the  arm  a  little  beyond 
(below)  the  attachment  of  the  tendon  of  this  muscle  to  the  humerus. 
Although  it  is  desirable  to  bring  the  edges  of  the  wound  together 
with  sutures  at  the  end  of  the  operation,  yet  one  should  not,  on  this 
account,  take  any  chance  in  leaving  suspicious  looking  integument, 
because  if  we  are  unable  to  close  the  wound  with  sutures  we  can 
cover  any  remaining  raw  space  with  skin  grafts. 


198 


THORAX. 


To  this  first  incision  a  second  is  added  which  runs  obliquely 
from  the  junction  of  the  middle  and  outer  thirds  of  the  clavicle 
down  into  the  upper  border  of  the  elliptical  incision.  The  skin  flaps 
which  are  thus  marked  out,  and  including  little  or  no  fat,  are  then 
dissected  away  from  the  breast  (tumor)  and  well  beyond  its  periph- 
ery. In  this  way  we  expose  the  tendon  of  the  pectoralis  major  ex- 
ternally, the  border  of  the  latissimus  dorsi  below  and  externally, 
and  above  the  space  or  groove  between  the  edge  of  the  deltoid  and 
the  upper  border  of  the  pectoralis  major;   in  this  space  the  cephalic 


Fig.  86.— Amputation  of  the  Breast.     Halsted-Meyer  incision  for  amputation 
of  the  breast  and  to  clean  out  the  axilla. 


vein  and  the  descending  branch  of  the  acromio-thoracic  artery  are 
found. 

The  tendon  of  the  pectoralis  major  is  next  divided  close  to  its 
attachment  to  the  humerus,  and  then,  following  along  the  upper 
border  of  this  muscle,  between  it  and  the  edge  of  the  deltoid  as  far 
as  the  clavicle,  this  muscle  (pectoralis  major)  is  cut  away  from  its 
attachment  to  this  bone  (clavicle)  and  reflected  downward,  thus  ex- 
posing the  next  underlying  layer,  or  "etage,"  which  consists  of  the 
pectoralis  minor  covered  by  its  fascia  and  some  loose  connective 
tissue.     The  fascia  that  covers  the  pectoralis  minor  is   continued 


OPERATIONS  UPON  THE  CHEST.  199 

upward  from  the  inner  border  of  the  muscle  as  the  costo-coracoid 
membrane,  and  is  attached  to  the  first  rib  and  under  surface  of  the 
clavicle,  thus  covering  in  the  structures  of  the  infraclavicular  region. 
This  fascia,  costo-coracoid  membrane,  which  is  perforated  by  the 
cephalic  vein  and  other  structures,  is  now  cut  away  from  its  attach- 
ment to  the  clavicle,  and  we  thus  uncover  the  structures  of  this 
region,  namely:  the  first  part  of  the  axillary  artery;  the  axillary 
vein,  which  lies  along  the  inner,  lower  side  of  the  artery;  and  close 
to  the  vein  a  chain  of  lymphatic  vessels  and  nodes,  connective  tis- 
sue, and  fat.  The  nerve  trunks,  which  are  derived  from  the  brachial 
plexus,  run  parallel  with  the  vessels,  but  above  them.  All  these 
structures  pass  upward  and  inward,  under  the  clavicle  and  beyond 
the  first  rib,  into  the  root  of  the  neck. 

Commencing  as  high  up  as  possible,  the  space  beneath  the 
clavicle  being  made  more  accessible  by  elevating  the  shoulder,  all 
the  fat  and  connective  tissue  are  cleaned  away  from  the  vessels, 
ligating  all  branches  as  they  are  met  with  and  working  outward  and 
downward  along  the  course  of  the  vessels.  After  the  space  beneath 
and  above  the  clavicle  has  been  thoroughly  cleared  of  all  fat  and 
connective  tissue,  the  pectoralis  minor  is  cut  close  to  its  origin  from 
the  coracoid  process  and  reflected  downward,  together  with  the  con- 
nective tissue  and  fat  that  lie  upon  it  and  also  the  fat  and  connective 
tissue  that  are  found  underneath  it  adjacent  to  the  vessels  and  nerves 
in  this  part  of  the  axilla.  This  dissection  is  continued  down  along 
the  course  of  the  vessels  and  nerves  as  far  as  the  attachment  of  the 
tendon  of  the  pectoralis  major  to  the  humerus,  and  should  be  thor- 
ough. The  tissue  which  is  thus  removed  should  not  be  taken  away 
piecemeal,  but  dissected  free  from  the  vessels,  etc.,  in  one  continuous 
mass,  and  allowed  to  remain  connected  with  the  general  tumor  mass. 

Now,  from  the  posterior  wall  of  the  axilla  and  from  the  side  of 
the  chest,  all  the  fat  and  connective  tissue  and  lymphatic  tissue  are 
cleared,  working  from  behind  forward  and  laying  bare,  behind,  the 
anterior  surface  of  the  latissimus  dorsi,  subscapularis,  and  teres  ma- 
jor muscles  (posterior  wall  of  the  axillary  space)  and,  upon  the  side 
of  the  thorax,  the  ribs  and  serratus  magnus  muscle.  Upon  the 
posterior  wall  of  the  axilla  the  subscapular  nerve,  in  company  with 
the  subscapular  vessels,  is  encountered.  This  nerve  should  be  saved, 
if  possible,  and  likewise  the  vessels,  if  they  have  not  already  been 
cut. 

Upon  the  side  of  the  chest  we  meet  the  long  thoracic  vessels 


200  THORAX. 

and  the  long  thoracic  nerve;  if  the  nerve  is  recognized  it  may  be 
possible  to  avoid  cutting  it. 

The  whole  mass — which  consists  of  the  breast  (tumor),  pectoral 
muscles  (major  and  minor),  axillary  contents,  etc. — is  now  grasped 
by  an  assistant  and  lifted  away  from  the  chest  wall  when  the  attach- 
ments of  the  pectoral  muscles  to  the  ribs  and  sternum  are  cut,  and 
then,  the  mass  being  gradually  turned  out  of  the  wound,  the  extirpa- 
tion is  completed  and  the  bare  wall  of  the  chest,  together  with  the 
axillary  vessels  and  the  nerves  which  accompany  them,  is  exposed  to 
view.  When  the  mass  is  lifted  away  from  the  chest  wall,  the  perfo- 
rating vessels — branches  of  the  intercostals  and  the  internal  mam- 
mary— may  be  seen  as  they  enter  the  posterior  surface  of  the  pec- 
toralis  major  and  care  should  be  taken  not  to  tear  these  or  cut  them 
too  close  to  the  surface  of  the  chest  wall,  as  it  might  then  be  difficult 
to  clamp  and  tie  them.  They  may  often  be  secured  with  clamps 
before  they  are  cut. 

The  edges  of  the  wound  are  brought  together  by  suture,  and 
if  too  much  integument  has  not  been  removed  the  wound  may  be 
thus  closed  entirely.  The  little  triangular  flap,  corresponding  to  the 
outer  edge  of  the  elliptical  incision,  is  turned  up  into  the  axilla  and 
fixed  there.  If  there  is  any  raw  space  remaining,  it  may  be  covered 
with  rubber  tissue  and  skin  grafted  later,  or  the  grafts  may  be  ap- 
plied at  once.  A  tube  may  be  placed  in  the  axilla  for  drainage,  and 
this  may  be  removed  on  the  sixth  or  seventh  day,  when  the  dressing 
is  changed. 

One  should  minimize  the  loss  of  blood  as  much  as  possible, 
clamping  vessels  before  or  immediately  after  they  are  cut. 

Ligation  of  the  Intercostal  Artery. — Each  intercostal  artery  is 
situated,  together  with  the  intercostal  vein  and  nerve,  beneath  the 
lower  border  of  the  corresponding  rib.  These  vessels  may  be  injured 
in  stab  wounds,  etc. 

At  times  it  becomes  necessary  to  resect  a  part  of  the  rib  sub- 
periosteally  in  order  to  get  at  the  bleeding  points.  It  is  necessary 
to  tie  both  ends  of  the  vessel. 

Ligation  of  the  Internal  Mammary  Artery.  —  To  secure  this 
vessel  one  must  resect  the  costal  cartilage  of  the  second  or  third 
rib  close  to  the  sternum  or  the  vessel  may  be  ligated  through  a 
transverse  incision  placed  midway  between  the  contiguous  cartilages 
and  close  to  the  sternum  in  the  third  intercostal  space.  The  vessel 
descends  upon  the  posterior  surface  of  the  anterior  chest  wall,  its 


OPERATIONS  UPON  THE  CHEST.  201 

vein  alongside  of  it;  it  is  accompanied  also  by  a  chain  of  lymphatic 
nodes. 

Thoracentesis. — Puncture  through  the  chest  wall  into  the  pleu- 
ral cavity. 

This  operation  may  be  performed  to  show  the  presence  and  to 
determine  the  nature  of  fluid  in  the  pleural  cavity  or  to  evacuate 
such  fluid.  If  for  diagnosis  only,  an  ordinary  hypodermic  syringe 
may  be  used.  If  necessary  to  evacuate  a  considerable  quantity  of 
fluid,  one  may  use  a  rather  good  sized  aspirating  needle  attached 
to  a  Dieulafoy  syringe.  The  patient  should  be  semirecumbent  or 
lying  down.  The  puncture  should  be  made  at  the  point  where  the 
physical  signs  locate  the  fluid.  To  anaesthetize  the  skin  a  spray  of 
ethyl  chloride  may  be  used.  Before  the  needle  is  introduced,  the 
skin  is  drawn  upward  or  downward  so  that  the  track  of  the  needle 
through  the  muscles  may  not  be  upon  the  same  level  as  the  puncture 
in  the  skin.  The  needle  is  thrust  into  the  chest  between  the  two- 
ribs  nearer  the  lower  than  the  upper  one. 

If  one  may  choose  the  point  at  which  the  needle  is  to  be  intro- 
duced, either  the  eighth  space,  just  below  the  angle  of  the  scapular, 
or  the  sixth  space,  in  the  middle  of  axilla,  just  in  front  of  the  border 
of  the  latissimus  dorsi,  is  usually  selected. 

The  fluid  should  be  evacuated  slowly,  and,  if  the  quantity  is 
great,  care  should  be  taken  not  to  remove  too  much.  One  should 
stop  if  persistent  cough  occurs  or  if  the  pulse  changes.  At  times,, 
the  needle  becomes  plugged  with  pieces  of  fibrin,  which  may  be 
dislodged  by  introducing  a  stylet  or  by  pumping  some  of  the  fluid 
back  into  the  pleural  cavity.  After  the  fluid  has  been  withdrawn  the- 
needle  is  removed  and  the  small  wound  in  the  skin  covered  with 
collodion,  etc. 

One  should  remember  that  the  lower  limits  of  the  pleural  cavity 
fall  short  of  the  free  border  of  the  ribs,  and,  further,  that  if  the 
needle  is  inserted  straight  inward  for  a  considerable  distance  it  may 
pass  through  the  pleura  and  diaphragm  into  the  abdominal  cavity. 

If  we  find  pus  in  the  pleural  cavity,  in  the  adult,  it  is  necessary 
to  establish  drainage,  resecting  part  of  a  rib.  In  the  child  it  often 
suffices  to  simply  evacuate  the  pus  with  the  needle  without  providing 
drainage. 

Thoracotomy.  —  This  means  cutting  through  the  wall  of  the 
chest,  usually  with  the  resection  of  part  of  a  rib,  for  the  purpose  of 
establishing  drainage. 


202  THORAX. 

The  patient  lies  upon  his  well  side,  and  should  be  anaesthetized. 
The  seventh  rib,  that  portion  of  it  which  lies  anterior  to  the  latis- 
simus  dorsi,  is  usually  resected,  as  this  is  not  covered  by  muscle  and 
is  sufficiently  low  for  proper  drainage. 

Immediately  before  proceeding  with  the  operation  one  should 
insert  the  exploring  needle  in  order  to  ascertain  positively  the  loca- 
tion of  the  pus,  and  there,  where  the  pus  is  located,  should  the 
entrance  into  the  pleural  cavity  be  made.  As  already  mentioned,  if 
we  have  the  choice,  the  seventh  rib  is  the  one  selected  for  resection. 

The  incision,  usually  about  two  inches  long,  corresponds  to  the 
course  and  direction  of  the  rib  to  be  excised;  it  is  carried  down 
through  the  soft  parts,  including  the  periosteum,  upon  the  surface 
of  the  rib.  With  the  elevator  the  periosteum  and  all  the  soft  parts 
are  peeled  off  the  bone,  which  is  thus  laid  bare.  Care  must  be  ex- 
ercised, in  working  around  the  upper  and  lower  borders  of  the  ribs 
to  reach  its  internal  surface,  not  to  perforate  the  pleura  nor  wound 
the  vessels  that  are  lodged  in  the  groove  along  the  lower  border  of 
the  rib.  When  the  length  of  bone  that  is  to  be  excised  has  been 
denuded  of  its  periosteum  it  is  cut  through  at  either  end  with  the 
sharp  bone  forceps.  The  opening  into  the  chest  cavity  is  made  by 
incising  the  pleura  with  the  knife.  The  opening  which  is  thus  made 
may  be  enlarged  by  introducing  an  artery  forceps,  the  blades  of 
which  are  spread  apart  as  they  are  withdrawn  so  as  to  make  a  hole 
large  enough  to  permit  exploration  of  the  interior  of  the  chest  with 
the  finger  and  the  introduction  of  one  or  two  good-sized  tubes. 

If  it  is  discovered,  with  the  finger  in  the  chest,  that  the  opening 
is  a  considerable  distance  above  the  bottom  of  the  pus  cavity,  one 
may,  in  order  to  facilitate  the  drainage,  make  a  second  counter- 
opening  at  a  lower  level:  through  the  eighth  space,  for  instance,  or 
even  lower,  depending  upon  the  part  of  the  chest  which  is  involved 
{see  limits  of  lower  edge  of  pleura).  The  drainage  tubes  should  be 
secured  to  the  edge  of  the  incision  in  the  skin  with  a  silk  stitch. 
If  the  skin  wound  is  unnecessarily  large,  it  may  be  partially  closed 
with  one  or  two  silk  sutures.  The  administration  of  20  or  30  minims 
of  aromatic  spirits  of  ammonia  hypodermically,  immediately  before 
the  opening  is  made  into  the  pleural  cavity,  will  often  ward  off  the 
condition  of  collapse  which  sometimes  occurs  at  this  time. 

Thoracectomy,  Resection  of  the  Chest  Wall  (Estlander). — An 
oval  or  U-shaped  flap,  consisting  of  the  skin  and  subcutaneous  fat, 
with  its  base  behind,  at  the  axillary  line,  is  raised  from  the  side  of  the 


OPERATIONS  UPON  THE  CHEST.  203 

chest,  exposing  three  or  four  ribs;  or  a  vertical  incision,  six  inches 
long,  may  be  made  in  the  axillary  line  over  the  fifth,  sixth,  seventh, 
and  eighth  ribs,  with  two  additional  incisions  along  the  course  of 
the  ribs,  the  middle  of  each  of  these  accessory  incisions  correspond- 
ing to  the  upper  and  lower  ends  of  the  vertical  incision.  The  two 
flaps  which  are  thus  marked  out  are  reflected,  one  backward  and  the 
other  forward,  exposing  four  to  six  inches  of  three  or  four  ribs. 

Each  rib  is  denuded  of  its  periosteum  all  around,  as  described 
in  the  preceding  operation,  and  resected  with  the  bone  pliers.  A  long 
incision  is  then  made  in  the  pleura  and  the  thickened  pleura  excised. 
The  bleeding  is  controlled  by  clamps  and  ligatures.  The  cavity  of 
the  pleura  may  be  curetted  if  thought  necessary.  The  edges  of  the 
skin  flap  are  brought  together  with  several  silk  sutures  and  the 
pleural  cavity  packed. 

Pleurectomy  (Fowler).— Detachment  and  excision  of  the  thick- 
ened, diseased  pleura,  visceral  and  parietal,  entire  or  in  part,  in  old, 
intractable  cases  of  empyema. 

An  incision  is  made  along  the  course  of  the  ribs  corresponding 
io  the  site  of  the  fistula,  which  is  always  present  (since  this  operation 
is  usually  practiced  in  cases  which  have  already  been  operated  upon 
unsuccessfully),  and  the  location  of  the  disease;  to  either  end  of  this 
incision  there  may  be  added  accessory  incisions,  an  anterior  and  a 
posterior.  The  flaps  that  are  thus  marked  out,  including  all  the  soft 
parts,  are  raised  so  as  to  expose  two  or  three  ribs  for  four  or  five 
inches  of  their  length.  Instead  of  the  incision  as  described  above 
-one  may  employ  an  elliptical  or  the  double  flap  incision,  as  described 
in  the  Estlander  operation. 

The  periosteum  is  stripped  off  two  or  three  ribs  with  the  ele- 
vator, and  then  from  three  to  five  inches  of  the  two  or  three  ribs 
that  have  been  thus  denuded  are  resected  with  the  bone  forceps. 
All  bleeding  points  should  be  clamped  and  ligated.  Cutting  from 
the  fistula,  the  parietal  (costal)  pleura,  which  is  now  exposed,  is 
opened  up  with  a  free  incision,  and  entrance  thus  gained  into  the 
suppurating  pleural  cavity.  The  pleura  which  invests  the  lung 
■(visceral)  is  incised,  and  by  blunt  dissection  with  the  finger  or  blunt- 
pointed  scissors  this  is  peeled  off  the  lung;  here  and  there  it  will  be 
necessary  to  cut  a  band  with  the  scissors.  In  many  cases  the  pleura 
may  be  separated  from  the  lung  with  comparative  ease,  and  this 
should  be  done  with  care,  so  as  not  to  tear  into  the  lung  tissue 
proper. 


204  THOKAX. 

As  the  decortication  of  the  lung  progresses  there  may  he  con- 
siderable oozing  from  the  denuded  lung  surface,  but  this  may  be 
controlled  by  compression  with  gauze  pads,  which  are  applied  to  the 
bleeding  surface  following  up  the  fingers  of  the  operator,  or  the 
blunt  scissors,  according  as  the  pleura  is  detached. 

After  the  pleura  has  been  peeled  off  the  lung  the  parietal  pleura 
is  stripped  off  the  chest  wall  and  then  off  the  diaphragm.  In  separ 
rating  the  pleura  from  the  contiguous  portion  of  the  pericardial  sac 
care  should  be  exercised  to  avoid  any  undue  pulling  or  tearing.  As 
a  rule,  the  pleura  is  fairly  easily  separated  and  removed. 

At  times  it  is  convenient  to  commence  the  detachment  of  the 
pleura  by  stripping  it  away  from  the  chest  wall;  it  is  then  peeled 
off  the  diaphragm  and  finally  from  the  surface  of  the  lung. 

Occasionally  the  conditions  that  exist  preclude  the  possibility 
of  excising  all  of  the  diseased  pleura,  and  under  these  circumstances- 
the  operator  must  content  himself  with  the  excision  of  the  visceral 
or  parietal  (costal  and  diaphragmatic)  pleura  in  part,  or  else  simply 
incise  the  visceral  pleura  and  strip  it  away  from  the  surface  of  the 
lung  without  removing  it. 

After  the  pleura  has  been  removed,  either  entire  or  in  part,  the 
cavity  in  the  chest  is  loosely  tamponed  with  gauze  and  the  edges  of 
the  skin  approximated  with  silk-worm  gut  sutures,  except  for  a  part 
of  its  extent,  where  the  tampon  emerges. 

As  a  rule,  as  the  detachment  of  the  pleura  from  the  lung  pro- 
gresses, the  lung  gradually  expands  more  and  more. 

This  operation  has  the  advantage  of  removing  the  pathological 
suppurating  membrane,  and  besides  eliminates  an  obstacle  to  the 
expansion  of  the  lung.  The  operation  is  not  advisable  in  cases  of 
diagnosible  pulmonary  tuberculosis.  The  discovery,  during  the 
course  of  the  operation,  of  tuberculous  deposits  in  the  lung  would 
warrant  the  surgeon  in  discontinuing  the  operation. 


PART  V. 

THE   ABDOMEN    AND    BACK. 


THE  ABDOMEN. 

The  abdomen  corresponds  to  the  lower  part  of  the  trunk,  and 
consists  of  a  cavity  with  elastic  muscular  walls. 

Within  the  cavity  are  contained  the  chief  part  of  the  alimentary 
canal  and  the  organs  of  digestion  and  the  kidneys,  etc.  These  organs 
are  all  more  or  less  movable,  and  are  provided  with  a  more  or  less 
complete  investment  of  peritoneum. 

Externally  the  abdomen  is  limited  above  by  the  free  border  of 
the  costal  cartilages  and  below  by  the  crest  of  the  iliac  bone  of 
either  side  and  Poupart's  ligaments.  The  walls  consist  almost  en- 
tirely of  soft  parts,  and  may  be  conveniently  considered  as  the  poste- 
rior and  the  antero-lateral.  The  capacity  of  the  abdominal  cavity  is 
greater  than  is  indicated  by  its  external  limitations. 

The  roof  of  the  abdominal  cavity  is  formed  by  the  diaphragm; 
below,  the  abdominal  cavity  includes,  on  either  side,  the  iliac  fossa 
and  communicates  through  a  wide,  heart-shaped  opening  with  the 
cavity  of  the  true  pelvis.  The  margin  of  the  inlet  into  the  pelvic 
cavity  is  called  the  pelvic  brim. 

The  interior  of  the  cavity  of  the  abdomen  is  lined  by  the  parietal 
layer  of  the  peritoneum,  and  is  entirely  shut  off  from  communica- 
tion with  the  exterior  of  the  body  except  in  the  female,  where  a 
communication  exists  through  the  vagina,  uterus,  and  Fallopian 
tubes,  and  this  is  frequently  the  channel  through  which  infection 
is  carried  to  the  peritoneum  from  without. 

The  Diaphragm,  which  forms  the  roof  of  the  abdominal  cavity, 
is  a  musculo-aponeurotic  structure  that  separates  the  cavity  of  the 
chest  from  that  of  the  abdomen.  It  is  dome-shaped,  bulging  into 
the  cavity  of  the  thorax  and  presenting  its  lower  concave  surface  to 
the  abdominal  cavity. 

It  arises  by  muscular  fibers,  which  vary  in  length,  from  the  inner 
surface  of  the  ensiform  process  of  the  sternum  and  from  the  inner* 
surfaces  of  the  cartilages  of  the  lower  ribs.     Behind,  it  arises  from 
the  ligamentum  arcuatum  externum  and  ligamentum  arcuatum  in- 

(205) 


206  ABDOMEN  AND  BACK. 

ternum  and  by  its  two  crura  from  the  anterior  surface  of  the  bodies 
of  the  three  upper  lumbar  vertebrae.  From  these  points  of  origin 
the  muscular  fibers  converge  and  are  continued  into  a  three-leafed 
aponeurotic  structure:  the  central  tendon  of  the  diaphragm.  Behind 
the  diaphragm  there  is  an  opening,  the  aortic,  through  which  the 
aorta  passes  from  the  thorax  into  the  abdomen;  the  posterior  bound- 
ary of  this  opening  corresponds  to  the  body  of  the  twelfth  dorsal 
vertebra.  In  the  back  part  of  the  diaphragm,  to  the  left  of  the 
middle  line,  there  is  an  opening  which  is  surrounded  by  muscular 
fibers  and  through  which  the  oesophagus  passes  to  the  cardiac  end 
of  the  stomach.  To  the  right  of  the  middle  line,  toward  the  front, 
at  the  junction  of  the  right  and  middle  segments  of  the  central 
tendon,  there  is  an  opening  for  the  passage  of  the  inferior  vena 
cava;  the  edges  of  this  opening  are  formed  of  aponeurotic  fibers. 
The  heart,  wrapped  in  its  pericardial  sac,  rests  upon  the  upper  sur- 
face of  the  central  tendon  of  the  diaphragm. 

In  front,  close  to  the  sternum,  on  either  side  of  the  bundle  of 
fibers  which  arises  from  the  ensiform  process,  there  is  a  space  where 
the  muscular  fibers  of  the  diaphragm  are  absent;  so  that,  in  this 
situation,  an  opening  exists  through  which  the  contents  of  one  cavity 
may  be  forced  into  the  other,  giving  rise  to  a  so-called  diaphragmatic 
hernia. 

On  the  right  side,  owing  to  the  presence  of  the  liver,  the  dia- 
phragm reaches  higher  into  the  chest  than  on  the  left.  The  thoracic 
surface  of  the  diaphragm  is  covered  by  a  thin  fascia,  the  fascia  endo- 
thoracica;  the  abdominal  surface  is  likewise  covered  by  a  fascia 
which  is  very  thin,  the  fascia  transversalis. 

The  Posterior  Wall  of  the  Abdomen,  the  lumbar  region  of  the 
back,  corresponds  to  the  five  lumbar  vertebras  and  to  the  several 
muscles  which  fill  in  the  space  between  the  last  rib  and  the  crest 
of  the  ilium  on  either  side  of  the  spinal  column.  Externally  we  find 
the  skin  and  beneath  this  the  subcutaneous  fatty  layer.  Between 
the  muscles  of  the  lumbar  region  are  interposed  strong  layers  of 
fascia — which  serve  to  strengthen  this  region  very  much.  The  in- 
ternal or  abdominal  aspect  of  the  posterior  wall  of  the  abdomen  is 
lined  by  that  part  of  the  transversalis  fascia  which  covers  the  psoas 
and  quadratus  lumborum  muscles. 

The  kidney,  inclosed  within  its  fatty  capsule,  is  located  in  the 
lumbar  region  between  the  transversalis  fascia — i.e.,  the  anterior 
layer  of  the  lumbar  fascia — and  the  parietal  peritoneum,  its  ante- 


ABDOMEN.  207 

rior  surface  only  being  covered  by  the  peritoneum;  so  that  the  organ 
is  thus  excluded  from  the  peritoneal  cavity. 

The  Antero-Lateral  Wall  of  the  Abdomen  is  made  up  of  several 
layers  of  soft  parts.  It  consists  of  the  skin  with  its  underlying  fatty 
layer;  several  broad,  flat  muscles,  the  oblique,  the  transversalis,  and 
the  recti;  and  the  aponeuroses  which  correspond  to  these  muscles;, 
the  fascia  transversalis  is  found  beneath  these  muscles,  and,  beneath 
the  fascia  transversalis,  the  subperitoneal  fat  is  encountered,  and,, 
finally,  deepest,  most  internal  of  all,  is  the  parietal  peritoneum. 

In  the  female  the  abdomen  is  more  rounded  and  contains  a  con- 
siderable pad  of  fat;  in  the  male,  especially  in  athletes,  the  fatty 
layer  is  less  marked  or  almost  entirely  absent;  so  that  the  markings 
of  the  muscles  show  through  the  skin  and  give  the  characteristic 
appearance  to  the  abdomen. 

In  the  middle  line,  about  midway  between  the  ensiform  process- 
and  the  symphysis  pubis,  there  is  a  well-marked  depression,  the  navel;, 
this  is  an  important  landmark,  although  its  position  may  vary  some- 
what in  different  individuals,  and  marks  the  place  where  the  fcetal 
umbilical  vessels  and  fcetal  channels  enter  and  pass  out  of  the  abdo- 
men. Above,  in  the  middle  line,  is  the  ensiform  process  of  the  ster- 
num, and  passing  downward  from  this  there  is  a  furrow  which  corre- 
sponds to  the  space  between  the  rectus  muscles,  but  which  does  not 
reach  downward  as  far  as  the  symphysis.  On  either  side  of  the- 
middle  line,  corresponding  to  the  outer  border  of  the  rectus,  is  the 
location  of  the  linea  semilunaris.  Below,  on  either  side,  the  anterior 
superior  iliac  spines — important  surgical  landmarks — may  be  seen,, 
and  upon  the  pubic  bones,  on  either  side  of  and  close  to  the  sym- 
physis, the  spinous  processes  of  the  pubes  may  be  felt. 

Corresponding  to  Poupart's  ligament,  which  reaches  from  the 
anterior  superior  spine  to  the  spine  of  the  pubes,  there  is  a  linear 
crease  in  the  skin  which  separates  the  abdomen  from  the  front  of 
the  thigh. 

The  whole  abdomen  is  covered  by  the  skin,  underneath  which 
is  the  subcutaneous  fat;  the  abdomen  is  a  favorite  site  for  the  accu- 
mulation of  fat  in  the  obese,  and  this  layer  varies  much  in  thickness 
in  different  individuals;  it  is  continuous  with  the  corresponding 
fatty  layer  upon  the  breast  and  below  with  the  fat  of  the  thighs. 
At  the  navel  the  fat  is  absent,  the  skin  being  depressed  and  fixed, 
to  the  aponeurosis  beneath,  so  that  the  depth  of  the  navel  corre- 
sponds to  the  thickness  of  the  abdominal  pad  of  fat.     The  subcuta- 


208  ABDOMEN  AND  BACK. 

neous  fatty  layer  is  readily  separated  from  the  underlying  muscle 
and  aponeurosis,  leaving  these  structures  covered  by  a  thin,  loose, 
cellular  fascia,  the  so-called  deep  layer  of  the  superficial  fascia,  but 
which  is  really  a  part  of  the  subcutaneous  connective-tissue  layer. 
This  fascia  is  more  intimately  attached  to  the  linea  alba  and  Pou- 
part's  ligament  and  to  the  pillars  of  the  external  inguinal  ring  than 
elsewhere.  From  the  pillars  of  the  ring  it  is  prolonged  downward 
around  the  spermatic  cord  and  into  the  scrotum,  where  it  is  con- 
tinuous with  the  dartos. 

The  Superficial  Vessels  of  the  Abdominal  Wall. — In  the  subcu- 
taneous fatty  layer  the  superficial  arteries  and  veins  ramify. 

Above,  branches  of  the  superior  epigastric,  which  perforate  the 
rectus  and  the  anterior  layer  of  its  sheath,  are  distributed  to  the 
integument  and  subcutaneous  tissue.  Below,  the  superficial  epi- 
gastric, which  is  derived  from  the  femoral,  curves  obliquely  upward 
across  Poupart's  ligament  toward  the  umbilicus  and  supplies  the  skin 
and  fat  in  this  region. 

Upon  the  sides  of  the  abdomen  branches  from  the  lumbar  ar- 
teries pierce  the  muscles  and  ramify  in  the  subcutaneous  tissue. 

These  vessels  are  all  accompanied  by  their  corresponding  veins. 
Underneath  the  skin  of  the  abdomen  are  seen  many  large  veins  which 
communicate  with  those  within  the  abdomen,  and  therefore  when 
the  blood-current  is  obstructed  in  the  portal  vein  or  the  vena  cava 
these  superficial  abdominal  veins  become  swollen  and  prominent  and 
are  readily  recognized  beneath  the  skin. 

After  the  skin  and  subcutaneous  fatty  layer,  including  the  thin 
deep  layer  of  the  superficial  fascia,  have  been  removed  from  the 
front  and  sides  of  the  abdomen,  the  broad,  strong  aponeurosis  of  the 
external  oblique  upon  the  front  of  the  abdomen  and  the  fleshy  por- 
tion of  this  same  muscle  upon  the  side  of  the  abdomen  are  exposed. 

The  Muscles  of  the  Antero-Lateral  Wall.  The  External 
Oblique  is  a  broad,  flat  muscle,  the  most  superficial  of  the  abdom- 
inal muscles,  and  occupies  the  side  of  the  abdomen.  The  muscle 
arises  by  fleshy  slips  from  the  external  surface  of  the  eight  lower 
ribs,  interdigitating  with  the  processes  of  origin  of  the  pectoralis 
major  and  the  latissimus  dorsi.  The  fibers  of  this  muscle  have  a 
general  oblique  direction,  downward,  forward,  and  inward,  terminat- 
ing in  the  broad,  strong  aponeurosis  which  occupies  the  front  of  the 
abdomen.  Those  fibers  which  arise  from  the  lowest  ribs  pass  almost 
directly  downward  and  are  attached  to  the  anterior  half  of  the  outer 


ABDOMEN.  209 

lip  of  the  crest  of  the  ilium.  The  posterior  free  horder  of  the  ex- 
ternal oblique  muscle  forms  the  anterior  border  of  the  triangle  of 
Pettit.  The  posterior  border  of  this  triangle  is  formed  by  the  outer 
free  edge  of  the  latissimus  dorsi,  its  base  by  the  crest  of  the  iliac 
bone,  its  floor  by  the  internal  oblique  muscle. 

The  aponeurosis  of  the  external  oblique  is  a  broad,  strong,  pearly 
white,  glistening,  fibrous  structure  which  occupies  the  front  of  the 
abdomen  and  is  exposed  after  the  integument  and  underlying  fatty 
layer  (superficial  fascia)  have  been  removed.  The  fibers  of  the  apo- 
neurosis are,  for  the  most  part,  directed  downward  and  inward,  cov- 
ering in  the  recti  and  joining  in  the  middle  line,  between  these 
muscles,  to  form  the  linea  alba. 

The  linea  alba  is  a  strong,  fibrous  band  which  reaches  from  the 
ensiform  cartilage  above  to  the  symphysis  pubis  below;  it  marks  the 
union  of  the  aponeuroses  of  either  side  and  separates  the  recti  from 
each  other.  The  linea  alba  is  interrupted  by  the  navel.  Above  the 
navel  the  linea  alba  is  broad:  in  the  epigastric  region  it  is  1  to  2 
cm.  wide,  and  below,  toward  the  navel,  becomes  still  broader.  Below 
the  navel,  however,  it  is  not  so  broad,  owing  to  the  closer  approxi- 
mation of  the  edges  of  the  recti.  Above,  where  it  is  broad,  it  is  thin 
from  before  backward,  and  below,  where  it  is  narrow,  it  is  thick 
from  before  backward.  Below,  at  its  attachment  to  the  symphysis 
pubis,  it  spreads  out  and  is  known  as  the  adminiculum  linege  albas. 

Those  fibers  of  the  aponeurosis  of  the  external  oblique,  that 
pass  from  the  anterior  superior  spine  of  the  ilium  downward  and 
inward  to  the  spine  of  the  pubes,  form  Poupart's  ligament;  where 
this  ligament  is  attached  to  the  pubic  spine,  the  aponeurosis  of  the 
external  oblique  splits  and  leaves  a  triangular  opening  which  is  called 
the  external  inguinal  ring,  and  through  this  the  spermatic  cord  in 
the  male,  and  the  round  ligament  in  the  female,  emerge.  Below  Pou- 
part's,  the  aponeurosis  is  continuous  with  the  fascia  lata  of  the  front 
of  the  thigh. 

Along  the  outer  edge  of  the  rectus,  at  the  linea  semilunaris,  the 
aponeurosis  of  the  external  oblique  is  blended  with  the  aponeuroses 
of  the  underlying  muscles;  from  the  linea  semilunaris  the  aponeu- 
rosis is  continued  inward,  forming  the  anterior  layer  of  the  sheath 
of  the  rectus,  and  in  the  middle  line  joins  with  that  of  the  opposite 
side  to  form  the  linea  alba. 

The  Internal  Oblique  Muscle  lies  beneath  the  external 
oblique  upon  the  side  of  the  abdomen,  a  thin,  loose,  cellular  con- 


210  ABDOMEN  AND  BACK. 

neetive  tissue  being  interposed  between  them.  The  fibers  of  this 
muscle  have  a  direction  the  opposite  to  those  of  the  external  oblique. 

This  muscle  arises  below  from  the  anterior  two-thirds  of  the 
middle  lip  of  the  crest  of  the  ilium  and  from  the  outer  half  of 
Poupart's  ligament.  From  this  origin  the  fibers  pass  in  a  general 
direction  upward  and  forward,  some  being  attached  to  the  lower 
border  of  the  cartilages  of  the  four  lower  ribs,  the  others  terminat- 
ing in  the  anterior  aponeurosis,  at  the  outer  border  of  the  rectus, 
the  linea  semilunaris.  The  lowermost  fibers,  which  arise  from  Pou- 
part's ligament,  pass  inward  and  then,  curving  downward,  join  with 
a  similar  process  from  the  transversalis  to  form  the  conjoined  tendon, 
which  is  attached  to  the  crest  of  the  os  pubis. 

The  Transversalis  is  the  deepest  of  the  three  broad  abdom- 
inal muscles.  It  occupies  the  side  of  the  abdomen  lying  next  beneath 
the  internal  oblique,  a  thin,  loose,  cellular  connective  tissue  inter- 
vening between  them.  Its  fibers  have  a  transverse  direction.  This 
muscle  arises  behind,  through  the  lumbar  fascia,  from  the  transverse 
processes  and  spines  of  the  lumbar  vertebrae;  above,  from  the  inner 
surface  of  the  six  lower  ribs;  below,  from  the  crest  of  the  ilium  and 
the  outer  one-third  of  Poupart's  ligament.  The  fibers  pass  forward 
and  inward,  and,  at  the  outer  border  of  the  rectus,  terminate  in  the 
anterior  aponeurosis.  Those  fibers  of  the  transversalis  which  arise 
from  Poupart's  ligament  pass  inward,  and  curving  downward  join 
with  a  similar  process  from  the  internal  oblique  to  form  the  con- 
joined tendon,  which  is  attached  to  the  crest  of  the  pubes  behind 
the  external  inguinal  ring.  Beneath  the  transversalis  muscle,  the 
transversalis  fascia,  which  lines  the  whole  inner  surface  of  the  ab- 
domen, is  found. 

The  Pectus  is  a  long,  flat  muscle  occupying  the  front  of  the 
abdomen,  one  on  either  side  of  the  middle  line,  the  linea  alba  being 
interposed  between  them. 

Above,  the  rectus  muscles  are  broad  and  attached  to  the  carti- 
lages of  the  fifth,  sixth,  seventh,  and  eighth  ribs  and  to  the  sides  of 
the  ensiform  cartilage.  Below,  they  become  narrow  and  are  attached 
to  the  symphysis  and  crest  of  the  pubes.  The  recti  are  marked  by 
several  transverse  fibrous  intersections,  which  are  united  to  the  ante- 
rior layer  of  the  sheath  of  this  muscle,  but  not  to  the  posterior;  they 
are  usually  three  in  number,  two  above  the  umbilicus  and  one  below. 

The  Aponeuroses  of  the  external  and  internal  oblique  and 
transversalis  are  blended  with  each  other  along  the  outer  border  of 


Fig.  87. — Transverse  Section  of  the  Abdomen  Above  the  Semilunar  Fold  of  Doug-las. 
AA,  anterior  layer  of  the  split  aponeurosis  of  the  oblique  and  transversalis  muscles — 
anterior  layer  of  sheath  of  the  rectus  ;  C,  descending  colon  ;  EO,  external  oblique 
muscle;  ES,  erector  spina;  muscle  ;  /,  intestine  suspended  by  the  mesentery;  IO.  in- 
ternal oblique  muscle  ;  K,  kidney ;  LD,  latissimus  dorsi  muscle ;  LS,  linea  semilunaris  ; 
M,  mesentery  (suspends  small  intestine  to  vertebral  column) ;  P,  psoas  muscle  :  P.  P,  P, 
peritoneum  lining  inner  aspect  of  abdominal  wall  ;  PA,  posterior  layer  of  split  aponeu- 
rosis of  the  oblique  and  transverse  muscles — posterior  layer  of  sheath  of  rectus; 
QL,  quadratus  lumborum  muscle  ;  R,  rectus  muscle  ;  T,  T,  transversalis  tascia ;  TR, 
transversalis  muscle. 


Fig.  88.— Transverse  Section  of  the  Abdomen  Below  the  Semilunar  Fold  of  Douglas, 
Showing  the  Entire  Aponeurosis  Passing  in  Front  of  the  Rectus  Muscle.  A,  aponeu- 
rosis of  the  abdominal  muscles  (oblique  and  transversalis),  passing  undivided  in  front 
of  the  rectus.     For  explanation  of  letters  see  Fi.^.  87. 


ABDOMEN.  211 

the  rectus  muscle.  Here,  corresponding  to  the  linea  semilunaris, 
they  form  one  aponeurotic  layer.  At  the  outer  border  of  the  rectus 
the  conjoined  aponeurosis  splits  into  two  layers, — an  anterior  and 
a  posterior, — and  these  include  the  rectus  between  them,  one  pass- 
ing in  front  of  the  muscle  and  the  other  behind  it  and  both  joining 
again  with  each  other,  between  the  recti,  in  the  middle  line,  to  form 
the  linea  alba.  This  disposition  of  the  aponeurosis  and  sheath  of 
the  rectus  is  very  simple  and  holds  for  the  upper  three-fourths  of 
the  muscle.  Corresponding  to  the  lower  fourth  of  the  rectus,  the 
whole  aponeurotic  layer,  without  splitting,  passes  in  front  of  the 
muscle;  so  that  this  lower  fourth  of  the  rectus,  upon  its  posterior 
aspect,  is  without  a  proper  sheath  and  is  covered  only  by  the  general 
fascia  transversalis. 

Upon  the  "posterior  aspect  of  the  rectus,  where  the  posterior 
layer  of  the  sheath  terminates,  it  presents  a  sharp,  curved  edge:  the 
semilunar  fold  of  Douglas. 

The  Fascia  Transversalis.  —  Lining  the  inner  surface  of  the 
transversalis  muscle  and  continued  over  the  whole  internal  surface 
of  the  abdomen  is  a  strong  fascia,  the  fascia  transversalis.  Above, 
this  fascia  is  thin  and  lines  the  abdominal  surface  of  the  diaphragm; 
below,  and  in  front,  especially  in  the  inguinal  region,  it  is  thicker. 
Behind,  upon  the  posterior  wall  of  the  abdomen,  it  covers  the  psoas 
and  quadratus  lumborum  muscles,  forming  here  the  anterior  layer 
of  the  lumbar  fascia;  it  is  also  attached  to  the  crest  of  the  ilium  and 
to  Poupart's  ligament  except  where  the  femoral  vessels  pass  under 
Poupart's  ligament  into  the  thigh.  It  covers  the  psoas  and  iliacus 
muscles  in  the  iliac  fossa,  where  it  is  known  as  the  fascia  iliaca,  and 
dips  into  the  true  pelvis,  which  it  lines  and  is  here  called  the  pelvic 
fascia.  All  these  fascia?,  although  having  different  names,  are  simply 
parts  of  the  general  transversalis  fascia. 

The  Parietal  Peritoneum. — The  whole  interior  of  the  abdominal 
cavity  is  lined  by  the  parietal  layer  of  the  peritoneum.  Between 
this  parietal  layer  of  the  peritoneum  and  the  transversalis  fascia 
there  is  a  layer  of  loose  connective  tissue  which  contains  a  consid- 
erable quantity  of  fat.  This  is  the  so-called  subperitoneal  connective 
tissue. 

Through  an  incision  in  the  anterior  abdominal  wall  placed  just 
to  the  left  of  the  middle  line,  we  may  study  the  round  ligament  of 
the  liver.  This  structure  is  the  remains  of  the  foetal  umbilical  vein 
and  reaches  from  the  posterior  aspect  of  the  navel  upward  and  to 


212  ABDOMEN  AND  BACK. 

the  right  as  far  as  the  under  surface  of  the  liver.  A  fold  of  the 
parietal  peritoneum,  which  is  reflected  from  the  anterior  abdominal 
wall  around  the  round  ligament,  is  called  the  falciform  ligament. 

The  presence  of  these  structures  would  complicate  somewhat 
entrance  into  the  abdomen  through  an  incision  placed  near  the 
middle  line  upon  the  right  side  of  the  navel,  and  therefore  when  it 
is  necessary  to  prolong  an  incision  in  the  middle  line  either  upward 
or  downward  beyond  the  navel  one  should  pass  to  its  left  side. 

Accompanying  the  round  ligament  of  the  liver  from  the  region 
of  the  umbilicus  are  several  veins  (one,  the  largest,  enters  the  portal 
system,  and  thus  establishes  a  communication  between  the  veins  of 
the  skin  of  the  abdomen  and  the  portal  circulation);  in  the  newborn 
infection  may  be  carried  from  the  region  of  the  navel  to  the  liver 
through  this  channel. 

Beaching  downward,  in  the  middle  line  from  the  umbilicus  to 
the  summit  of  the  bladder,  is  the  urachus.  This  is  a  musculo-fibrous 
cord, — the  remains  of  the  fcetal  allantois, — and  may  be  found  more 
or  less  pervious  in  the  child  or  adult;  so  that  a  communication  may 
thus  exist  between  the  umbilicus  and  the  bladder.  As  the  parietal 
peritoneum,  which  lines  the  posterior  surface  of  the  anterior  abdom- 
inal wall,  passes  over  the  urachus,  it  is  raised  in  the  form  of  a  distinct 
longitudinal  fold:    the  plica  vesico-umbilicalis  media. 

The  Deep  Vessels  of  the  Abdominal  Wall. — Between  the  layers 
of  the  muscles  of  the  abdomen  the  deep  vessels  of  the  abdominal 
wall  ramify.  Above  are  found  the  terminal  branches  of  the  internal 
mammary,  the  superior  epigastric,  and  the  musculo-phrenic.  The 
superior  epigastric  is  continued  from  the  thorax,  through  the  open- 
ing in  the  diaphragm,  between  its  costal  and  sternal  portions,  and 
then,  piercing  the  posterior  layer  of  the  sheath  of  the  rectus,  it  sup- 
plies this  muscle  and  gives  off  branches  which  perforate  the  muscle 
and  the  anterior  layer  of  its  sheath  to  supply  the  subcutaneous  tissue 
and  skin  of  the  abdomen.  It  anastomoses  with  branches  of  the  su- 
perficial epigastric  and  deep  (inferior)  epigastric. 

Below,  the  deep  epigastric  and  the  deep  circumflex  iliac,  which 
are  derived  from  the  external  iliac,  are  encountered;  these  are  given 
off  just  before  this  vessel  passes  under  Poupart's  ligament  into  the 
thigh  to  become  the  femoral. 

The  deep  epigastric  is  directed  upward  and  inward  toward  the 
umbilicus,  resting  upon  the  posterior  surface  of  the  rectus,  be- 
tween  the   transversalis   fascia   and   the   parietal   peritoneum,   and 


Fig.  89. — The  Regions  of  the  Abdomen  as  Indicated  bv  Two  Transverse  Lines  Drawn  through  the 
Tips  of  the  Tenth  Costal  Cartilages  and  the  Anterior  Superior  Iliac  Spines  and  Two  Oblique  Lines 
Drawn  from  the  Tips  of  the  Tenth  Costal  Cartilages  down  to  the  Pubic  Spines.  D,  duodenum  indicated 
in  red  (the  dotted  portion  represents  that  portion  of  the  duodenum  which  lies  beneath  the  liver, 
transverse  colon,  and  stomach) ;  G,  gall-bladder  ;  L,  liver;  S,  stomach  ;  TC,  transverse  colon. 


ABDOMEN.  213 

enters  the  substance  of  this  muscle  below  the  semilunar  fold  of 
Douglas,  supplying  it  and  anastomosing  with  the  end  branches  of 
the  superior  epigastric.  Some  branches  from  this  vessel  pierce  the 
anterior  layer  of  the  sheath  of  the  rectus  muscle  and  ramify  in  the 
fatty  layer  beneath  the  skin. 

The  deep  circumflex  iliac  passes  upward  and  outward  beneath 
and  parallel  with  Poupart's  ligament  toward  the  anterior  superior 
iliac  spine;  it  then  runs  along  the  crest  of  the  ilium  and  after 
piercing  the  transversalis  fascia  is  distributed  to  the  muscles  of  the 
abdomen. 

From  behind  come  the  abdominal  branches  of  the  lumbar  ar- 
teries: usually  four.  They  pass  forward  between  the  muscles  and 
anastomose  with  the  branches  of  the  musculo-phrenic,  superior  epi- 
gastric, the  deep  epigastric,  and  the  deep  circumflex  iliac.  These 
arteries  are  all  accompanied  by  their  corresponding  vein. 

The  Regions  of  the  Abdomen. — The  surface  of  the  abdomen  is 
marked  off  into  areas  by  several  lines  which  intersect  each  other. 
Two  of  these  are  transverse,  the  upper  passing  through  the  tips  of 
the  tenth  ribs,  the  lower  through  the  highest  points  of  the  iliac 
crests.  These  are  crossed  by  two  lines  which  pass  from  the  tip  of 
the  tenth  rib  of  either  side  downward  and  inward  to  the  pubic 
spine. 

Above  the  upper  transverse  line  is  the: — 

(a)  Eegio  epigastrica; 
between  the  two  transverse  lines  is  the 

(b)  Eegio  mesogastrica; 

and  below  the  lower  transverse  line  is  the 

(c)  Eegio  hypogastrica. 

The  regio  epigastrica  is  subdivided  into  three  portions: — 

1.  Eegio  epigastrica  proper. 

2.  Eegio  hypochondriaca  dextra. 

3.  Eegio  hypochondriaca  sinistra. 

The  regio  mesogastrica  is  also  subdivided  into  three  portions: — ■ 

1.  Eegio  umbilicalis. 

2.  Eegio  abdominis  lateralis  dextra. 

3.  Eegio  abdominis  lateralis  sinistra. 

The  regio  hypogastrica  is  subdivided  into  three  portions: — 

1.  Eegio  pubica. 

2.  Eegio  inguinalis  dextra. 

3.  Eegio  inguinalis  sinistra. 


214  ABDOMEN  AND  BACK. 

THE  BACK. 

When  we  speak  of  the  back  we  mean  the  whole  posterior  part 
of  the  trunk.  The  back  may  be  divided  into  three  regions:  the 
dorsal,  the  lumbar,  and  the  sacral. 

It  is  better  to  consider  the  back  as  a  whole,  since  these  regions 
merge  directly  into  each  other  without  any  definite  dividing  line. 

Above  the  back  is  limited  by  the  vertebra  prominens  and  below 
by  the  tip  of  the  coccyx.  The  dorsal  portion  corresponds  to  the 
chest,  and  includes  the  dorsal  vertebrae  and  the  ribs,  the  scapulae 
and  the  muscles  of  this  region.  The  lumbar  portion  forms  the  poste- 
rior wall  of  the  abdominal  cavity,  and  includes  the  five  lumbar  ver- 
tebra? and  the  thick  mass  of  muscle  on  either  side  which  fills  in  the 
space  between  the  last  rib  and  crest  of  the  ilium. 

The  sacral  region  corresponds  to  the  posterior  wall  of  the  true 
pelvic  cavity  and  includes  the  sacrum  and  the  coccyx. 

In  the  middle  of  the  back  there  is  a  longitudinal  furrow  in 
which  the  spinous  processes  of  the  vertebras,  from  the  seventh  cer- 
vical, vertebra  prominens,  above,  to  the  sacrum  below,  may  be  dis- 
tinctly felt;  those  which  correspond  to  the  sacrum  are  less  prominent. 

To  either  side  of  this  median  furrow  there  is  a  prominent  mass 
formed  by  the  longitudinal  muscles  of  the  back.  These  masses  ex- 
tend from  the  sacrum  to  the  occiput,  and,  the  more  pronounced  they 
are,  the  deeper  is  the  median  groove. 

In  the  dorsal  region,  on  either  side,  are  the  scapulas — shoulder- 
blades.  These  bones  are  triangular  in  shape  and  are  located  between 
the  first  and  eighth  ribs  toward  the  outer  part  of  the  thorax.  The 
inner  or  vertebral  border  of  the  scapula  is  nearly  parallel  with  the 
spinous  processes  of  the  vertebras  when  the  arm  hangs  by  the  side. 
This  bone  is  freely  movable  and  its  position  varies  according  to  the 
position  of  the  upper  extremity.  The  spine  of  the  scapula  is  felt 
beneath  the  skin  and  may  be  traced  outward  and  upward;  its  outer 
end,  which  is  prolonged  outward  and  flattened  from  above  down- 
ward, is  called  the  acromion  process  and  overhangs  the  shoulder- 
joint,  articulating  with  the  outer  end  of  the  clavicle.  The  lower 
extremity  of  the  scapula,  the  angle,  corresponds  to  the  eighth  rib, 
and  is  a  surgical  landmark  of  some  value. 

The  skin  and  subcutaneous  connective  tissue  of  the  back  is 
continuous  with  the  corresponding  layers  of  the  adjoining  parts  of 
the  trunk.  The  subcutaneous  tissue  is  rather  firm  and  fibrous  and 
contains  a  varying  amount  of  fatty  tissue.     The  deep  fascia  of  the 


BACK.  215 

back  is  a  strong,  dense,  fibrous  layer  which  covers  in  the  superficial 
muscles;  it . is  attached  in  the  middle  line  to  the  spinous  processes 
of  the  vertebra?  and  may  be  traced  upward,  upon  the  trapezius  mus- 
cle, as  far  as  the  occipital  bone,  to  which  it  is  attached.  In  the  dorsal 
region  it  is  attached  to  the  subcutaneous  surface  of  the  spine  of  the 
scapula.  Below  it  is  attached  to  the  crest  of  the  ilium  and  to  the 
sacrum. 

The  Muscles  of  the  Back  are  numerous  and  may  be  divided  into 
several  layers. 

Fikst  Layee  of  Muscles. — Trapezius  and  latissimus  dorsi. 

The  Trapezius  is  a  broad,  flat  muscle,  one  on  either  side;  to- 
gether they  are  lozenge-shaped  and  occupy  the  dorsal  and  cervical 
regions.  Each  muscle  arises  from  the  superior  curved  line  of  the 
occipital  bone,  from  the  ligamentum  nucha?,  which  corresponds  to 
the  spinous  processes  of  the  cervical  vertebras,  and  from  the  spinous 
processes  of  all  the  dorsal  vertebrse.  From  this  extensive  origin  the 
muscle  of  each  side  is  attached  as  follows:  Those  fibers  which  arise 
from  the  occipital  bone  pass  downward,  outward,  and  forward,  and 
are  attached  to  the  upper  surface  of  the  outer  one-third  of  the  clav- 
icle; those  from  the  dorsal  and  cervical  vertebrae  converge  and  are 
attached  to  the  whole  length  of  the  upper  border  of  the  spine  of 
the  scapula.  That  portion  of  the  muscle  which  corresponds  to  the 
lower  cervical  and  upper  dorsal  vertebra?  shows  an  aponeurotic  origin, 
which,  together  with  that  of  the  opposite  side,  is  oval  in  shape. 

The  Latissimus  Dorsi  is  broad,  triangle-shaped,  and  fiat,  and 
occupies  the  lumbar  and  lower  dorsal  regions,  being  partly  over- 
lapped by  the  trapezius. 

It  arises  by  aponeurotic  fibers  from  the  spinous  processes  of  the 
five  or  six  lower  dorsal  and  the  lumbar  vertebra?.  Below  the  aponeu- 
rotic origin  of  the  latissimus  dorsi  is  intimately  blended  with  the 
aponeurosis  that  covers  the  erector  spina?;  the  muscle  also  arises 
from  the  back  part  of  the  outer  lip  of  the  crest  of  the  ilium  and  by 
three  or  four  slips  from  the  external  surface  of  the  lower  ribs.  From 
this  extensive  origin  the  fibers  all  converge,  and  at  the  angle  of  the 
scapula  they  form  a  thick,  flat,  fleshy  muscle,  which,  making  a  half- 
turn  upon  itself,  passes  upward,  in  front  of  the  teres  major,  and  is 
attached  by  a  narrow,  flat,  aponeurotic  tendon  to  the  inner  lip  of 
the  bicipital  groove  of  the  humerus.  The  tendon  of  the  latissimus 
dorsi  and  the  teres  major  form  the  lower  border  of  the  posterior 
wall  of  the  axilla. 


216  ABDOMEN  AND  BACK. 

Secoxd  Later  of  Muscles: 

Levator  anguli  scapulae. 

Khoniboideus  < 

(  Minor. 

The  Levator  Anguli  Scapulae  is  located  in  the  side  of  the  neck 
and  the  upper  dorsal  region.  It  arises  by  tendinous  slips  from  the 
tubercles  on  the  transverse  processes  of  the  four  upper  cervical  ver- 
tebrae; passing  down  the  side  of  the  neck,  it  is  attached  to  the  upper 
part  of  the  inner,  or  vertebral,  border  of  the  scapulae. 

The  Rhomboids  are  two  flat  muscles  placed  one  above  the  other, 
both  lying  upon  the  same  plane  and  really  forming  one  broad,  flat 
muscle.  Internally  they  are  attached  to  the  spinous  processes  of 
the  last  cervical  and  four  or  five  upper  dorsal  vertebrae,  and  exter- 
nally to  the  vertebral  border  of  the  scapula. 

Third  Layer  of  Muscles. — Splenius;  serratus  posticus,  supe- 
rior and  inferior. 

The  Splenius  is  located  in  the  back  of  the  neck  and  upper  dorsal 
region,  reaching  from  the  occiput  downward  as  far  as  the  sixth  dorsal 
vertebrae  below. 

The  Serratus  Posticus. — The  superior  and  inferior  are  two  thin, 
flat  muscles,  the  superior  being  located  in  the  upper  dorsal  region, 
the  inferior  in  the  lower  dorsal  and  lumbar  regions. 

The  Muscles  of  the  Fourth  Later  are  numerous  and  have 
a  longitudinal  direction,  reaching  upward,  alongside  of  the  spinal 
column,  from  the  sacrum  as  far  as  the  occiput.  The  muscles  of  this 
group,  except  the  erector  spinas,  are  of  but  little  importance  sur- 
gically. 

The  Erector  Spinae  below,  in  the  lumbar  region,  forms  a  large 
musculo-tendinous  mass,  which  fills  in  the  space  on  either  side  of 
the  lumbar  part  of  the  spinal  column,  being  superimposed  upon  the 
quadratus  lumborum  in  this  region.  From  the  lumbar  region  the 
erector  spinae  is  continued  upward  into  the  dorsal  region.  In  the 
dorsal  region  this  muscle  divides  into*  a  number  of  processes,  each 
of  which  receives  a  different  name  and  is  described  as  a  separate 
muscle.  The  erector  spinae  below,  in  the  lumbar  region,  is  covered 
by  a  dense  aponeurotic  structure:  the  posterior  layer  of  the  lumbar 
fascia.  The  muscle  arises  from  the  back  part  of  the  iliac  crest  and, 
through  its  aponeurosis,  from  the  posterior  surface  of  the  sacrum 
and  from  the  spinous  processes  of  the  lumbar  and  two  or  three  lower 


BACK.  217 

dorsal  vertebrae.  The  erector  spinas  is  included  between  the  poste- 
rior and  middle  layers  of  the  lumbar  fascia.  The  quadratus  lum- 
borum  lies  beneath  the  erector  spinas. 

In  the  lumbar  region  the  erector  spinas  forms  a  well-marked 
muscular  mass,  and  its  outer  edge  is  an  important  guide  in  cutting 
down  upon  the  kidney. 

The  Muscles  oe  the  Fifth  Layer  are  numerous,  and  are  made 
up,  for  the  most  part,  of  longitudinal  strips  that  connect  adjoining 
vertebras  to  each  other.  They  ar,e  all  more  or  less  continuous  with 
each  other,  but  receive  different  names  in  different  regions.  They 
are  lodged  in  the  groove  upon  either  side  of  the  spinous  processes, 
and  extend  from  the  sacrum  to  the  occiput. 

The  Quadratus  Lumborum  is  really  a  muscle  of  the  abdomen, 
forming  part  of  its  posterior  wall;  it  is  quadrilateral  in  shape,  broad, 
and  thick.  It  fills  in  the  space  on  either  side  of  the  spinal  column 
from  the  last  rib  to  the  crest  of  the  ilium.  It  is  broader  below  at 
its  attachment  to  the  crest  of  the  ilium  than  above  at  its  insertion 
into  the  last  rib.  Its  outer  border  is  free  and  lies  more  external  than 
that  of  the  erector  spinas,  and  forms  an  important  surgical  guide. 

The  muscle  arises  by  aponeurotic  fibers  from  the  upper  part 
of  the  ilio-lumbar  ligament  and  from  the  adjacent  part  of  the  crest 
of  the  ilium  for  a  distance  of  about  two  inches.  From  this  origin 
the  muscle  passes  upward  and  is  inserted  into  the  inner  half  of  the 
lower  border  of  the  last  rib  and,  by  fleshy  slips,  to  the  transverse 
processes  of  the  four  upper  lumbar  vertebras. 

The  muscle  is  inclosed  between  the  middle  and  anterior  layers 
of  the  lumbar  fascia,  and  lies  directly  beneath  the  erector  spinas, 
from  which  it  is  separated  by  the  middle  layer  of  the  lumbar  fascia. 

The  Lumbar  Fascia. — In  the  lumbar  region  there  is  a  strong 
aponeurotic  structure  called  the  lumbar  fascia;  it  is  through  this 
fascia  that  the  transversalis  muscle  is  connected  with  the  spine. 
The  lumbar  fascia  is  usually  described  as  consisting  of  three  layers 
(see  Fig.  87).  The  anterior  layer  is  rather  thin,  covers  the  front 
surface  of  the  quadratus  lumborum  muscle,  and  is  attached  inter- 
nally to  the  anterior  aspect  of  the  transverse  processes  of  the  lumbar 
vertebras;  above,  this  layer  of  the  fascia  is  attached  to  the  lower 
border  of  the  last  rib,  where  it  constitutes  the  ligamentum  arcuatum 
externum.  The  middle  layer  of  the  lumbar  fascia  is  strong,  is  at- 
tached to  the  apices  of  the  transverse  processes  of  the  lumbar  ver- 
tebras, and  is  placed  between  the  quadratus  lumborum  and  erector 


218  ABDOMEN  AND  BACK. 

spinas  muscles.  The  posterior  layer  of  the  lumbar  fascia  is  attached 
to  the  apices  of  the  spinous  processes  of  the  lumbar  vertebras;  it 
forms  the  posterior  aponeurotic  covering  of  the  erector  spinas,  and 
is  blended  with  the  aponeurosis  of  origin  of  the  latissimus  dorsi.  At 
the  outer  border  of  the  quadratus  lumborum  the  three  layers  of  the 
lumbar  fascia  unite  to  form  a  single  aponeurotic  layer,  through  which 
the  transversalis  muscle  is  connected  with  the  spinal  column. 

The  Psoas  and  Iliacus  Muscles. — In  the  back  of  the  abdomen, 
lying  one  upon  either  side  of  the  spinal  column,  is  the  psoas  muscle. 
It  arises  by  slips  from  the  transverse  processes  and  bodies  of  the  last 
dorsal  and  the  lumbar  vertebras,  and  passing  downward  joins  with 
the  iliacus. 

The  iliacus  muscle  occupies  the  iliac  fossa,  taking  its  origin 
there,  and,  together  with  the  psoas,  passes  out  of  the  abdomen  under 
Poupart's  ligament  to  be  attached  to  the  lesser  trochanter  of  the 
femur  and  to  the  surface  of  the  bone  immediately  below  this. 

The  psoas  and  iliacus  are  covered  by  a  fascia,  the  iliac  fascia. 
This  is  simply  a  part  of  the  general  transversalis  fascia  of  the  ab- 
domen. That  part  which  covers  the  psoas  muscle  is  thickened  above, 
where  it  is  known  as  the  ligamentum  arcuatum  internum;  laterally, 
beyond  the  edge  of  the  psoas  muscle,  this  fascia  is  continuous  with 
that  which  covers  the  quadratus  lumborum:  the  anterior  layer  of 
the  lumbar  fascia.  The  iliac  fascia  covers  the  iliacus  muscle  also, 
and  is  attached  to  the  crest  of  the  ilium  and  the  brim  of  the  pelvis, 
and  to  Poupart's  ligament  except  where  the  femoral  vessels  pass 
down  into  the  thigh.  In  this  situation  the  fascia  is  continued  down- 
ward, under  Poupart's  ligament,  behind  the  vessels  into  the  thigh, 
covering  the  anterior  surface  of  the  psoas-iliacus  muscle. 

The  parietal  peritoneum  is  spread  out  over  the  inner  surface 
of  the  posterior  wall  of  the  abdomen.  The  kidney,  incased  in  its 
capsule  of  fat,  lies  between  this  layer  of  the  peritoneum  and  the 
fascia  which  covers  the  quadratus  lumborum  muscle. 

The  Spinal  Column,  etc. — The  spinal  column  is  made  up  of  the 
vertebras  and  intervertebral  pads,  the  sacrum,  and  the  coccyx;  it  is 
located  at  a  considerable  depth  from  the  surface  of  the  body.  The 
spinal  column  gives  solidity,  combined  with  flexibility,  to  the  trunk, 
and  furnishes  a  canal  to  contain  and  protect  the  spinal  cord. 

"We  may  palpate  the  body  of  the  first  cervical  vertebra,  the  atlas, 
through  the  mouth,  its  anterior  tubercle  lying  just  behind  the  soft 
palate;  those  vertebras  which  lie  below  this  down  as  far  as  the  fifth 


BACK.  219 

cervical  may  also  be  palpated  through  the  mouth.  Lower  in  the 
neck  and  in-the  dorsal  region  palpation  of  the  bodies  of  the  vertebras 
is  impossible.  The  bodies  of  the  lumbar  vertebra?  can  be  felt  through 
the  abdomen,  especially  in  thin  persons.  The  sacrum  and  coccyx 
may  be  palpated  through  the  rectum. 

The  laminae  meet  behind,  in  the  middle  line,  to  form  the  spinous 
processes  and  inclose  the  canal  which  contains  the  spinal  cord. 

In  the  cervical  and  lumber  regions  the  spaces  between  the 
laminae  are  broad,  and  a  knife-blade  might  easily  be  introduced 
through  these  into  the  spinal  canal.  This  could  not  be  so  readily 
done  in  the  dorsal  region,  however,  where  the  laminae  and  spines 
overlap  each  other  like  the  shingles  on  a  roof. 

The  spaces  between  the  laminae  are  occupied  by  the  ligamenta 
subflava,  which  serve  to  complete  the  canal  and  even  it  out  upon 
its  inner  aspect. 

The  bodies  of  the  vertebrae  are  joined  to  each  other  by  the  ante- 
rior and  posterior  common  ligaments;  the  posterior  common  liga- 
ment, besides  connecting  the  bodies  of  the  vertebrae  with  each  other, 
also  serves  to  even  out  the  irregularities  upon  the  internal  aspect  of 
the  canal.  The  spines  of  the  vertebrae  are  connected  with  each  other 
by  ligaments:   the  interspinous  and  the  supraspinous. 

The  spinal  column  presents  three  curves  in  the  sagittal  direc- 
tion, antero-posterior,  and  one  lateral  with  the  concavity  toward  the 
left  (aorta). 

Fractures  of  the  spine  usually  involve  the  fifth  and  sixth  cer- 
vical, last  dorsal,  and  first  lumbar  vertebrae,  and  are  usually  caused 
by  indirect  violence,  the  curved  parts  of  the  spine  being  bent  beyond 
the  limit  of  their  elasticity. 

The  spinal  canal  is  widest  in  the  neck  and  triangular  upon  sec- 
tion; narrower  in  the  dorsal  region  and  circular  upon  section.  It  is 
narrowest  at  the  level  of  the  ninth  dorsal.  From  the  eleventh  dorsal 
it  becomes  wider  again.  In  the  sacrum  it  is  flattened  from  before 
backward  and  terminates  upon  the  posterior  surface  of  this  bone. 

The  spinal  canal  shows  a  series  of  openings — intervertebral — 
upon  either  side,  just  behind  the  bodies,  for  the  passage  of  nerves 
and  vessels  to  and  from  the  canal.  The  contents  of  the  canal  are 
well  protected.  It  is  an  uncommon  accident  for  an  instrument  to 
penetrate  into  the  canal,  and  unusual  force  is  required  to  injure  the 
cord  inclosed  within  these  bony  walls. 

Contained  within  the  canal  is  the  spinal  cord,  which  is  much 


220  ABDOMEN  AND  BACK. 

smaller  and  shorter  than  the  canal;  the  spinal  cord  commences  at 
the  upper  border  of  the  posterior  arch  of  the  atlas,  where  it  is  con- 
tinuous with  the  medulla,  and  terminates  below  in  the  conus  ter- 
minalis  on  a  level  with  the  lower  border  of  the  first  lumbar  vertebra. 
From  the  conus  terminalis  the  cord  is  prolonged  still  farther  down- 
ward as  the  filum  terminale. 

The  spinal  cord,  as  it  lies  within  the  canal,  is  inclosed  by  the 
dura  and  pia  mater.  The  dura  mater  is  continuous  with  the  dura 
mater,  periosteum,  of  the  skull,  and  is  adherent  to  the  margin  of 
the  foramen  magnum.  Here  it  splits  into  two  layers,  the  external 
of  which  is  applied  to  the  inner  aspect  of  the  spinal  canal  as  a  lining 
membrane,  periosteum,  whereas  the  other,  the  inner  layer,  forms  a 
loose,  sack-like  envelope  for  the  cord,  the  dura  mater  proper,  and 
is  continued  all  the  way  down  to  the  coccyx,  where  it  is  blended  with 
the  periosteum  of  that  bone.  Between  these  two  layers  there  is  a 
space  in  which  veins  and  arteries  ramify  and  into  which  hemorrhage 
may  take  place  and  spread  up  and  down  the  canal.  Each  nerve,  at 
its  exit  from  the  spinal  canal,  has  prolonged  upon  it  a  tubular  proc- 
ess, which  is  derived  from  the  dura  and  pia  mater. 

Beneath  this  dura  mater  sheath  is  the  pia  mater,  a  reticular 
structure  like  that  which  invests  the  brain;  the  outer  surface  of  the 
pia  is  known  as  the  arachnoid,  and  the  inner,  which  is  applied  di- 
rectly to  the  surface  of  the  cord,  is  known  as  the  pia  mater  proper 
and  carries  the  vessels  which  penetrate  into  the  substance  of  the  cord 
to  supply  it. 

Between  the  two  surfaces  of  the  pia  there  is  a  space,  which  is 
called  the  subarachnoid  space,  and  which  is  subdivided,  cut  up,  by 
numerous  trabecule  into  a  net-work  of  small  spaces.  In  the  sub- 
arachnoid space,  between  the  two  layers  of  the  pia,  the  cerebro- 
spinal fluid  is  found.  From  the  pia  mater  laterally,  between  the 
roots  of  the  nerves,  there  arises  a  longitudinal  septum  which  is  at- 
tached to  the  inner  surface  of  the  dura  mater  by  a  number  of  proc- 
esses. The  line  of  origin  from  the  pia  is  continuous.  The  line  of 
attachment  to  the  dura  mater  is  interrupted.  This  is  known  as  the 
ligamentum  dentatum. 

The  surfaces  of  the  dura  and  the  pia  mater  (arachnoid)  are  not 
joined  to  each  other  except  for  occasional  strands  of  connective  tis- 
sue that  unite  them  here  and  there.  The  space  between  the  dura 
and  pia  mater  is  known  as  the  subdural  space. 


SURGICAL  ANATOMY  OF  THE  STOMACH.  221 

Each  nerve-root  is  provided  with  an  envelope  consisting  of  a 
process  of  the  pia  and  dura. 

Arteries  that  supply  the  cord  consist  of  hranch.es  from  the  ver- 
tebral, intercostals,  lumbar,  and  lateral  sacral;  from  above  down- 
ward these  vessels  pass  through  the  intervertebral  foramina  to  sup- 
ply the  coverings  and  the  cord. 

Veins,  in  the  form  of  plexuses,  are  found  on  the  front  and  back 
of  the  cord,  within  the  canal,  between  the  two  layers  of  the  dura, 
or,  better,  between  the  dura  proper  and  the  periosteum. 

THE  STOMACH. 

The  Surgical  Anatomy  of  the  Stomach. — The  stomach  is  a  pear- 
shaped,  pouched  portion  of  the  alimentary  canal  with  a  capacity  of 
from  five  to  eight  pints.  It  is  suspended  obliquely  in  the  upper  part 
of  the  abdomen,  upon  the  left  side,  extending  from  the  oesophagus  to 
the  duodenum.  Its  walls  are  thick,  and  consist  of  a  serous,  a  mus- 
cular, a  submucous,  and  a  mucous  membrane  coat. 

The  larger  end  of  the  stomach,  the  cardiac,  is  above  and  toward 
the  left  side;  the  smaller  end,  the  pyloric,  is  below  and  toward  the 
right  side. 

The  oesophageal  opening  is  called  the  cardiac,  and  the  opening 
into  the  duodenum,  the  pyloric,  orifice.  The  dilated  left  end  of  the 
stomach— i.e.,  that  part  to  the  left  of  the  oesophageal  opening — is 
called  the  fundus;  the  middle  part,  the  body;  and  the  right,  rather 
constricted  portion,  the  pylorus. 

The  stomach  presents  an  upper  or  right  border,  the  lesser  curva- 
ture, and  a  lower  or  left  border,  the  greater  curvature.  It  has  an 
anterior  Avail  directed  forward  and  upward  and  a  posterior  wall 
which  is  directed  backward  and  downward. 

The  adult  stomach,  moderately  distended,  measures  in  its  long- 
est diameter  from  ten  to  twelve  inches;  from  the  greater  to  the 
lesser  curvature,  four  to  five  inches;  and  from  the  anterior  to  the 
posterior  wall  about  three  and  one-half  inches.  When  the  stomach 
is  empty  the  first  and  second  diameters  are  diminished  and  the  third 
disappears,  as  the  walls  come  into  contact  with  each  other.  In  this 
condition  the  mucous  membrane  lining  is  thrown  into  numerous 
folds  and  ruga?. 

The  opening  between  the  pylorus  and  the  duodenum  is  indi- 
cated by  a  well-marked  thickening  of  the  wall  of  the  stomach,  which 
may  be  felt  from  without;  it  is  made  up  of  circular  muscular  fibers, 


222  ABDOMEN  AND  BACK. 

which  act  as  a  sphincter  and  which  serve  to  shut  off  the  cavity  of 
the  stomach  from  that  of  the  duodenum. 

The  stomach  lies  in  the  left  hypochondriac  and  the  epigastric  re- 
gions; about  five-sixths  part  of  the  organ  lies  to  the  left  of  the  mid- 
dle line,  the  pyloric  end  lying  to  the  right  of  the  middle  line.  The 
cardiac  orifice  is  located  one  inch  below  the  diaphragm,  to  the  left 
of  the  eleventh  dorsal  vertebra,  and  at  a  depth  of  11  cm.  from  the 
front  wall  of  the  abdomen,  on  a  line  directly  behind  the  articulation 
of  the  seventh  left  costal  cartilage  with  the  sternum.  The  pyloric 
orifice  lies  to  the  right  and  a  little  below  the  ensiform  cartilage  and 
nearer  the  anterior  wall  of  the  abdomen.  The  direction  of  a  line 
drawn  from  the  cardiac  orifice  to  the  pyloric  orifice  of  the  stomach 
would  be  downward  and  to  the  right.  The  fundus  of  the  stomach 
reaches  upward  as  high  as  the  level  of  the  sixth  costal  cartilage,  and 
is  separated  from  the  base  of  the  left  lung  by  the  diaphragm. 

The  anterior  surface  of  the  stomach,  toward  the  left,  is  in  rela- 
tion with  the  seventh,  eighth,  and  ninth  ribs,  the  diaphragm  being 
interposed;  toward  the  right,  the  pyloric  end  of  the  stomach  is  cov- 
ered by  the  left  lobe  of  the  liver. 

Below  the  stomach,  along  its  great  curvature  and  attached  to 
it  by  the  so-called  gastro-colic  ligament,  is  the  transverse  colon. 

A  triangular  area  of  the  anterior  wall  of  the  stomach — near  the 
left  free  border  of  the  ribs — is  in  direct  relation  with  the  anterior 
abdominal  wall,  and  is  here  accessible  for  operation.  The  base  of 
this  triangular  space  is  indicated  by  a  transverse  line,  which  corre- 
sponds to  the  transverse  colon  and  greater  curvature  of  the  stomach 
and  which  is  drawn  through  the  tip  of  the  ninth  rib  (costal  carti- 
lages) of  either  side.  The  other  lines  of  the  triangle  are,  upon  the 
left,  the  free  border  of  the  ribs,  and,  upon  the  right  side,  a  line  cor- 
responding to  the  anterior  thin  edge  of  the  left  lobe  of  the  liver, 
which  is  drawn  from  the  tip  of  the  tenth  right  costal  cartilage  to  the 
tip  of  the  eighth  left  costal  cartilage. 

Behind  the  stomach  lie  the  pancreas,  with  the  splenic  vessels 
passing  along  its  upper  border;  the  upper  part  of  the  left  kidney 
and  suprarenal  capsule;    and,  toward  the  left,  the  spleen. 

Behind  the  pyloric  end  of  the  stomach  are  the  duodenum,  portal 
vein  and  common  bile-duct,  the  head  of  the  pancreas  and  the  first 
lumbar  vertebra,  the  crura  of  the  diaphragm,  the  aorta  with  the 
cceliac  axis,  the  solar  sympathetic  plexus,  the  thoracic  duct,  vena  cava 
inferior,  etc. 


SURGICAL  ANATOMY  OF  THE  STOMACH. 


223 


The  spleen  lies  to  the  left  of  the  stomach  and  rather  behind  it. 
The  gall-bladder  is  in  relation  with  the  pyloric  end  of  the  stomach. 

The  stomach  is  entirely  enveloped  by  the  peritoneum,  which 
forms  its  serous  coat;    above,  extending  between  the  transverse  fis- 


Fig.  90. — Sagittal  Section  to  Show  the  Arrangement  of  the  Great  and 
Lesser  Omenta,  etc.  GM,  great  omentum;  L,  liver;  LM,  lesser  omentum; 
8,  stomach;  TG,  transverse  colon;  *,  situation  where  the  layers  of  the  great 
omentum  become  fused  to  that  portion  of  the  peritoneum  which  invests  the 
transverse  colon,  thus  joining  the  latter  to  the  lower  border  of  the  stomach. 


sure  of  the  liver  and  the  lesser  curvature  of  the  stomach,  the  two 
layers  of  the  peritoneum  join  to  form  the  lesser  omentum,  gastro- 
hepatic  ligament,  between  the  layers  of  which,  toward  its  right  edge, 
the  hepatic  artery,  portal  vein,  and  common  bile-duct  are  located. 


224  ABDOMEN  AND  BACK. 

Below,  at  the  greater  curvature,  the  two  layers  of  peritoneum, 
after  enveloping  the  stomach,  again  join  to  form  the  great  omen- 
tum through  which-  the  transverse  colon  is  attached  to  the  greater 
curvature  of  the  stomach.  That  portion  of  the  great  omentum 
which  joins  the  stomach  and  transverse  colon  is  called  the  gastro- 
colic ligament.  Toward  the  left,  the  two  layers  of  peritoneum  which 
cover  the  anterior  and  posterior  surfaces  of  the  stomach  are  also 
joined — gastro-splenic  omentum — and  are  reflected  over  upon  the 
spleen,  inclosing  this  organ  and  connecting  it  with  the  fundus  of 
the  stomach.  Between  the  layers  of  the  gastro-splenic  omentum 
the  vasa  brevia  pass  to  the  fundus  of  the  stomach. 

The  arteries  which  supply  the  stomach  are  derived  from  the 
cceliac  axis,  and  consist  of  large  branches  which  course  along  the 
lesser  and  greater  curvatures;  these  vessels  give  off  large  branches, 
which  ramify  upon  the  anterior  and  posterior  walls  of  the  stomach, 
coursing  from  the  periphery  toward  the  middle  of  each  surface; 
along  the  lesser  curvature,  the  pyloric  artery,  a  branch  of  the  hepatic, 
and  the  gastric  artery  anastomose;  along  the  greater  curvature, 
anastomosing  with  each  other,  are  the  gastro-epiploica  dextra,  from 
the  hepatic,  and  the  gastro-epiploica  sinistra,  from  the  splenic.  The 
vasa  brevia,  from  the  splenic,  ramify  upon  the  left  end,  fundus,  of 
the  stomach. 

The  stomach  may  be  reached  through  several  incisions: — 

1.  In  the  linea  alba,  commencing  one  inch  below  the  ensiform 
cartilage  and  reaching  down  to  the  umbilicus.  After  cutting  through 
the  skin,  subcutaneous  fat,  and  the  strong  fibrous  layer,  the  linea 
alba,  the  parietal  peritoneum  is  reached  and  incised.  If  necessary 
to  prolong  this  incision  beyond  the  navel,  it  should  be  carried  to  the 
left  of  that  structure. 

2.  Yon  Hacker's  incision:  Through  the  left  rectus  muscle,  one 
and  one-fourth  inches  to  the  left  of  the  linea  alba,  penetrating 
bluntly  between  the  fleshy  fibers  of  the  rectus  muscle  with  the  handle 
of  the  knife. 

3.  Just  to  the  left  of  the  linea  alba,  through  the  inner  portion 
of  the  rectus  muscle,  thus  avoiding  an  incision  through  the  linea 
alba. 

4.  Fenger's  incision:  One  finger's  breadth  distant  from  and 
parallel  with  the  free  border  of  the  ribs  (left  side).  This  incision 
may  be  two  to  three  inches  in  length  or  longer,  its  upper  end  being 
placed  a  short  distance  from  the  tip  of  the  ensiform  cartilage. 


SURGICAL  ANATOMY  OF  THE  STOMACH. 


225 


Fig.  91. — Incisions  to  Reach  Abdominal  Viscera,  etc.  B,  Battle  incision;  C,  left 
colostomy;  F,  Fenger  incision  for  stomach;  G,  incisions  for  operations  upon  gall-blad- 
der (perpendicular  and  oblique) ;  H,  von  Hacker's  incision  for  gastrostomy  (in  the  mid- 
dle line,  alongside  of  E,  is  the  linea  alba  incision  for  operations  upon  stomach) ;  MB, 
McBurney  incision  for  appendicectomy;    SC,  incision  for  suprapubic  cystotomy. 


226 


ABDOMEN  AND  BACK. 


Hemorrhage  may  be  controlled  by  clamping  vessels  as  they  are 
met  and  cut,  afterward  ligating  any  that  may  require  it. 

OPERATIONS  UPON  THE  STOMACH. 

Gastroplication. — The  folding  in  of  a  portion  of  the  wall  of  the 
stomach  in  order  to  diminish  the  size  of  the  organ.  This  operation 
was  first  performed  by  Bircher,  and  is  especially  applicable  to  cases 
of  dilatation  without  stenosis  of  the  pyloric  orifice. 

The  abdominal  incision,  five  to  six  inches  in  length,  may  be 


Fig.  92. — Gastroplication.  Lower  border  of  the  stomach  is  turned  up  and 
stitched  near  the  lesser  curvature  with  a  single  row  of  sutures  (4),  method 
of  Bircher;  with  four  rows  of  sutures  (1,  2,  3,  4),  method  of  Weir. 


placed  a  finger's  breadth  distant  from  and  parallel  with  the  left  free 
border  of  the  ribs,  commencing  above  near  the  tip  of  the  ensiform 
process,  or  it  may  be  located  in  the  linea  alba,  reaching  from  a  point 
one  inch  below  the  tip  of  the  ensiform  process  downward  as  far  as 
the  umbilicus. 

Through  either  of  these  incisions  the  stomach  may  be  brought 
out  upon  the  abdominal  wall. 

According  to  Bircher,  the  anterior  wall  of  the  stomach  is  folded 
upon  itself;  so  that  the  greater  curvature  may  be  brought  up  close 
to  the  lesser  curvature  and  fixed  in  this  position  with  a  row  of  inter- 


OPERATIONS  UPON  THE  STOMACH. 


227 


Tirpted  silk  sutures;  these  should  take  a  good,  broad  bite  in  the  wall 
of  the  stomach,  including  its  serous  and  muscular  coats.  Care  should 
be  exercised  that  the  sutures  do  not  penetrate  through  the  entire 
thickness  of  the  wall  of  the  stomach.  Twelve  to  fourteen  sutures  are 
usually  required. 


93. — Cross   Section   of   the   Stomach   After   Gastroplication 
according  to  the  Method  of  Bircher. 


According  to  Weir,  the  fixation  may  be  made  with  three  or  four 
separate  tiers  of  sutures,  one  superimposed  upon  the  other.  After 
the  stomach  has  been  brought  out  through  the  abdominal  incision, 
its  anterior  wall,  corresponding  to  the  long^1  diameter  of  the  organ, 


94. — Cross  Section  of  Stomach  After  Gastroplication;  the  Turned-Up 
Portion  Fixed  by  Four  Rows  of  Sutures.     (Weir.) 


is  inverted,  and  the  edges  of  the  furrow  thus  made  in  the  wall  of 
the  stomach  united  with  a  row  of  continuous  or  interrupted  silk 
sutures.  A  second  row  of  sutures  is  then  introduced  parallel  with 
and  about  one  inch  distant  from  the  first.     A  third  and  finally  a 


228  ABDOMEN  AND  BACK. 

fourth  row  may  be  introduced,  the  last  row  joining  the  greater  curva- 
ture to  the  upper  part  of  the  anterior  wall  of  the  stomach  near  its 
lesser  curvature.  In  this  way  six  or  eight  inches  of  the  stomach 
wall  may  be  reefed  in  and  the  organ  materially  reduced  in  size.  No 
doubt  the  folding  of  the  stomach  wall  is  made  more  secure  when 
several  rows  of  sutures  are  used. 

Gastrotomy. — This  operation  consists  in  making  an  incision  into 
the  stomach  for  the  purpose  of  extracting  a  foreign  body  lodged  in 
the  stomach  or  impacted  low  down  in  the  oesophagus;  for  explora- 
tion of  the  interior  of  the  stomach,  ulcer,  hemorrhage,  etc.,  and  to 
treat  strictures  in  the  lower  part  of  the  oesophagus. 

Immediately  preceding  any  operation  upon  the  stomach  the 
organ  should  be  emptied  and  irrigated,  if  the  conditions  permit,  with 
the  stomach  tube.  This  is  best  done  after  the  patient  has  been 
anaesthetized. 

The  incision  may  be  made  in  the  middle  line  through  the  linea 
alba,  three  inches  long,  commencing  above  about  one  inch  below  the 
ensiform  process,  and  extending  downward  toward  the  umbilicus;  or 
an  incision  may  be  made  just  to  the  left  of  the  linea  alba,  passing 
through  the  inner  margin  of  the  left  rectus  muscle;  or  the  Fenger 
incision,  parallel  with  the  free  border  of  the  left  ribs,  may  be  em- 
ployed. This  last  incision  (Fenger)  is  probably  the  best  if  the  ulti- 
mate object  is  to  reach  the  oesophagus. 

Having  carried  the  incision  down  to  the  parietal  layer  of  the 
peritoneum,  this  is  picked  up  with  two  toothed  forceps  and  a  small 
incision  made  between  them  with  the  knife;  through  this  the  finger 
is  introduced,  and  upon  the  finger,  with  a  blunt-pointed  scissors,  the 
opening  in  the  peritoneum  is  enlarged  so  as  to  correspond  in  length 
with  the  incision  in  the  abdominal  wall.  Two  fingers  are  then  intro- 
duced into  the  abdomen  and  the  stomach  searched  for.  If  there  is 
a  foreign  body  in  the  stomach,  this  may  oftentimes  be  felt  and  serves 
as  a  guide  to  the  stomach.  The  thin  anterior  edge  of  the  left  lobe 
of  the  liver  may  be  always  readily  recognized,  and  this  is  a  good 
guide  to  the  stomach,  as  the  stomach  lies  directly  underneath  this 
organ,  being  partly  covered  by  it;  that  part  of  the  anterior  surface 
of  the  stomach  which  is. not  covered  by  the  liver  is  accessible  for 
operation;  it  is  seized  with  two  fingers  and  drawn  out  of  the  ab- 
dominal incision.  Pads  of  dry,  sterile  gauze  are  then  placed  about 
the  stomach  and  tucked  into  the  abdominal  incision  and  the  rest 
of  the  operation  done  extraperitoneally.     If  the  stomach  is  dimin- 


OPERATIONS  UPON  THE  STOMACH.  229 

ished  in  size  there  may  be  some  difficulty  in  bringing  it  out  through 
the  incision  .upon  the  abdomen. 

One  should  not  mistake  the  transverse  colon  for  the  stomach. 
Tbe  transverse  colon  lies  below  and  close  to  the  greater  curvature, 
being  connected  with  the  greater  curvature  by  the  great  omentum 
(gastro-colic  ligament);  the  great  omentum  is  suspended  free,  apron- 
like, from  the  transverse  colon,  and  when  this  part  of  the  intestine 
is  drawn  out  upon  the  abdomen  the  great  omentum  is  drawn  out 
with  it;  the  colon  can  be  further  recognized  by  its  sacculation,  by 
the  little  fatty  appendices  attached  to  it,  and  by  the  strise  which  run 
along  its  length. 

The  wall  of  the  stomach  is  smooth,  and  the  blood-vessels  rami- 
fying upon  its.  surface  have  a  characteristic  course,  converging  from 
the  periphery  toward  the  center;  the  gastro-epiploica  dextra  and 
sinistra  run  along  the  greater  curvature  from  either  end  of  the 
stomach,  anastomosing  with  each  other. 

A  portion  of  the  stomach  wall  which  has  been  drawn  out  through 
the  abdominal  incision  is  now  incised.  When  opened,  care  should 
be  taken  to  catch  any  escaping  contents,  especially  if  the  stomach 
has  not  been  previously  emptied,  washed  out,  in  order  to  prevent 
these  entering  the  abdominal  cavity. 

The  stomach  is  best  incised  in  its  long  diameter,  and  the  in- 
cision may  vary  from  one  to  three  inches.  Bleeding  vessels  may  be 
caught  with  artery  forceps.  Venous  hemorrhage  stops  after  the 
artery  forceps  have  been  applied  for  a  short  time,  but  spurting  arte- 
rial branches  should  be  clamped  and  tied  with  either  fine  silk  or  fine 
catgut. 

After  the  removal  of  the  foreign  body  or  examination  of  the 
interior  of  the  stomach,  either  by  the  finger  introduced  or  by  in- 
spection, bringing,  piece  by  piece,  different  areas  of  its  inner  surface 
into  the  incision,  treatment  of  ulcer  by  curette  or  Paquelin,  etc.,  the 
opening  may  be  closed. 

The  closure  of  the  incision  in  the  stomach  is  best  effected  by  a 
continuous  Lembert  suture  of  fine  silk,  which  is  applied  with  a  fine 
curved  surgeon's  needle.  This  suture  includes  the  serous  and  mus- 
cular coats  and  takes  a  good  bite,  each  loop  being  drawn  fairly  tight. 
This  line  of  suture  may  be  reinforced  by  a  second  similar  row  of 
Lembert  sutures  which  bury  the  first.  Before  closing  the  opening 
in  the  stomach  wall  its  edges  should  be  wiped  with  a  wet  bichloride 
pad.     After  the  closure  has  been  accomplished  the  parts  should  be 


230  ABDOMEN  AND  BACK. 

again  mopped  off  with  the  bichloride  pad,  followed  by  salt  solution, 
and  the  stomach  then  returned  into  the  abdomen. 

The  wound  in  the  abdomen  is  closed  first  by  a  continuous  catgut 
stitch  which  approximates  the  edges  of  the  parietal  peritoneum,  and 
then  a  sufficient  number  of  interrupted  silk-worm  sutures — each  in- 
cluding the  skin,  aponeurosis,  and  muscle — are  introduced. 

If  the  stomach  is  opened  for  the  purpose  of  treating  a  cicatricial 
stricture  of  the  lower  end  of  the  oesophagus,  the  finger  may  be  intro- 
duced through  the  incision  in  the  stomach  into  the  oesophageal 
opening;  at  times  it  is  necessary  to  make  a  little  steady  pressure 
with  the  finger  before  this  opening  yields  so  as  to  allow  the  finger 
to  enter.  Conical  gum  bougies  of  increasing  caliber  may  then  be 
introduced  into  the  oesophagus  beyond  the  stricture.  If  the  stricture 
is  dense  and  unyielding,  one  may,  according  to  the  method  of  Abbe,, 
pass  a  thin  bougie,  carrying  a  strand  of  braided  silk,  up  into  the 
oesophagus,  through  and  beyond  the  stricture,  so  that  the  end  of  the 
bougie  with  the  silk  cord  may  be  felt  in  the  pharynx.  The  piece  of 
silk  is  then  grasped  in  the  back  of  the  pharynx  through  the  mouth 
or  through  an  opening  which  may  be  made  for  that  purpose  in  the 
side  of  the  neck  and  oesophagus,  and  the  bougie  again  withdrawn 
through  the  opening  in  the  stomach.  The  silk  string  having  been 
thus  carried  through  the  oesophagus,  a  conical  bougie  is  now  again 
introduced  into  the  oesophagus  from  below  through  the  opening  in 
the  stomach;  this  bougie  should  be  large  enough  to  become  tightly 
engaged  in  the  stricture;  the  ends  of  the  silk  string  are  then  seized, 
and  after  this  has  been  drawn  back  and  forth  several  times  it  will  be 
observed  that  the  bougie  can  be  passed  farther  and  farther  into  the 
stricture;  and  one  may  thus  use  bougies  of  increasing  caliber  until 
the  stricture  is  sufficiently  relieved.  The  incision  of  the  stricture 
which  is  made  by  the  silk  string  is  accomplished  with  but  little 
hemorrhage.  The  bougie  and  string  are  withdrawn  and  a  tube 
permitted  to  remain  in  the  oesophagus,  with  its  end  projecting 
through  the  opening  in  the  stomach  and  out  through  the  abdominal 
incision. 

Besides  this  a  second  tube  is  left  in  the  stomach  for  the  pur- 
pose of  feeding.    The  abdominal  incision  is  left  partly  open. 

One  may  again  repeat  the  procedures  if  necessary,  after  an  in- 
terval of  a  few  days. 

The  gastric  fistula  which  results  either  closes  spontaneously  or 
may  be  closed  by  a  secondary  plastic  operation. 


OPERATIONS  UPON  THE  STOMACH. 


231 


Pyloroplasty  (Heinecke  and  Mikulicz). — For  cicatricial  stricture 
of  the  pylorus  causing  obstruction  to  the  emptying  of  the  stomach. 

The  stomach  is  exposed  through  a  median  incision  and  its  py- 
loric end  drawn  out  through  the  incision.  Pads  are  then  properly 
placed  to  protect  the  peritoneal  cavity  during  the  rest  of  the  opera- 
tion. 


Fig.  95. — Pyloroplasty.    Horizontal  incision  into  the  pylorus. 

The  pylorus  is  incised  in  its  long  axis,  a  clean  cut  being  made 
through  all  its  coats;  this  incision  should  be  from  4  to  6  cm.  long; 
the  edges  of  the  incision  are  then  drawn  widely  apart  by  tenacula  in 
the  middle  of  each  edge,  and  in  this  way  the  transverse  incision  be- 
comes converted  into  a  vertical  one.    In  this  position,  after  sponging 


Fig.  96.— Pyloroplasty. 


Horizontal  converted  into  a  vertical  Incision 
and  sutures  placed. 


its  margins  with  a  bichloride  pad,  the  opening  is  closed  by  a  row  of 
interrupted  Lembert  sutures  which  take  a  good,  deep,  and  broad  bite, 
these  being  reinforced  and  buried  by  a  second  row  of  Lembert  sutures, 
which  may  be  continuous.  All  the  sutures  are  of  silk.  Care  should 
be  taken  to  close  the  opening  accurately,  especially  in  the  middle: 
the  points  which  correspond  to  the  extremities  of  the  original  incision. 


232  ABDOMEN  AND  BACK. 

The  result  is  a  marked  widening  of  the  pyloric  orifice.  The  wound 
in  the  abdomen  is  closed  in  the  usual  way. 

Gastrostomy. — The  formation  of  a  permanent  gastric  fistula  for 
the  purpose  of  feeding  in  cases  of  simple  or  malignant  stricture  of 
the  oesophagus.  The  fistula  should  permit  the  introduction  of  nutri- 
ment and  at  the  same  time  prevent  the  escape  of  stomach  contents. 

Von  Hacker's  Method. — The  operation  may  be  done,  if  nec- 
essary, under  cocain  ansesthesia.  This  method  is  used  only  in  ad-, 
vanced  cases,  where  time  presses. 

The  incision,  three  inches  long,  is  made  through  the  left  rectus 
muscle;  it  should  be  placed  about  one  and  one-fourth  inches  to  the 
left  of  the  middle  line,  commencing  above,  about  one  inch  below 
the  free  border  of  the  ribs.  After  passing  through  the  integument 
the  anterior  layer  of  the  sheath  of  the  rectus  is  reached  and  incised, 
and  then,  separating  between  the  fibers  of  this  muscle  bluntly  with 
the  handle  of  the  knife,  the  posterior  layer  of  the  sheath  of  the 
rectus  is  exposed;  after  this  layer  has  been  incised  the  parietal  peri- 
toneum is  exposed;  this  is  picked  up  with  two  toothed  forceps  and 
between  these  a  small  incision  is  made  with  the  knife.  Through  this 
small  opening  the  finger  is  introduced  into  the  abdomen  and  the 
incision  further  enlarged  with  blunt-pointed  scissors.  Now,  corre- 
sponding to  the  middle  of  the  abdominal  incision,  upon  each  side,  the 
parietal  peritoneum  is  fixed  to  the  edge  of  tbe  muscle  with  a  single 
catgut  suture.  Two  fingers  are  then  introduced  into  the  abdomen 
and  the  anterior  wall  of  the  stomach  is  seized  and  drawn  out  of  the 
wound.  Two  silk  sling  sutures  are  introduced  into  the  wall  of  the 
stomach;  these  should  take  a  good,  broad  bite  in  the  wall  of  the 
stomach,  but  should  not  penetrate  into  its  cavity,  and  should  be 
placed  about  one  and  one-half  inches  apart  and  one  above  the  other; 
they  are  simply  to  serve  as  tractors  to  steady  the  stomach  in  the 
wound,  and  should  not  be  withdrawn  until  after  the  stomach  has 
been  opened.  They  are  useful  guides  when  the  time  comes  later  to 
incise  the  stomach. 

Now,  with  a  fairly  large  curved  surgeon's  needle  a  silk  suture 
is  passed  through  the  edges  of  the  upper  part  of  the  abdominal  in- 
cision; this  should  include  the  whole  thickness  of  the  abdominal 
wall,  care  being  taken  not  to  omit  the  parietal  peritoneum.  This 
suture  is  not  tied.  A  similar  stitch  is  then  passed  through  the  lower 
end  of  the  wound,  and  this  is  also  left  untied.  Now,  just  below  the 
upper  suture,  the  first  one  introduced,  another  similar  suture   is 


OPERATIONS  UPON  THE  STOMACH.  233 

passed,  but  this  includes,  in  addition,  the  wall  of  the  stomach:  one 
should  take  a  good,  broad  bite  in  the  wall  of  the  stomach,  but  with- 
out entering  its  cavity;  this  suture  is  placed  just  above  the  upper 
of  the  two  sling  tractor  stitches;  again,  in  the  lower  part  of  the 
wound,  a  stitch  is  taken  similar  to  the  preceding  which  likewise  in- 
cludes the  wall  of  the  stomach  and  lies  just  below  the  lower  sling 
stitch.  These  four  sutures  are  then  tied  and  cut  short,  and  the  wound 
i«  thus  partly  closed  above  and  below,  and  the  stomach  fixed  at  the 
same  time  to  the  edges  of  the  incision  by  two  good,  firm  sutures. 
The  wall  of  the  stomach  is  now  further  fixed  to  the  edges  of  the 
incision  by  three  or  four  additional  silk  stitches  on  each  side;  thesa 
may  be  of  fine  chromicized  catgut  or  of  fine  silk. 

The  wound  is  then  packed  and  dressed,  and  after  the  lapse  of 
two  days  the  stomach  is  opened  between  the  two  sling  sutures  which 
were  left  in  situ.  It  is  better  to  make  this  opening  in  the  stomach 
with  a  sharp  knife,  clamping  any  bleeding  points,  rather  than  with  a 
Paquelin,  which  causes  a  sloughy  wound  which,  when  it  cicatrizes, 
may  be  larger  than  desired.  The  opening  in  the  stomach  should  be 
one-half  inch  long,  just  large  enough  to  admit  a  tight-fitting  tube. 
The  sling  stitches  may  then  be  withdrawn. 

If  one  should  desire  to  open  the  stomach  immediately,  which 
should  be  avoided  if  possible,  the  union  of  the  stomach  to  the  edges 
of  the  abdominal  incision  must  be  made  more  accurate  in  order  to 
prevent  possible  leakage  and  peritoneal  infection. 

Method  of  Ssabanajew  and  Fkanck.  —  A  very  satisfactory 
operation.  The  incision  (Fenger)  should  be  placed  parallel  wilh  the 
left  free  border  of  the  ribs  and  should  be  not  more  than  two  inches 
long,  commencing  above  to  the  side  of  the  ensiform  process.  The 
middle  of  the  incision  should  be  opposite  the  tip  of  the  cartilage  of 
the  eighth  rib.  The  incision  is  continued  down  through  the  muscles 
and  parietal  peritoneum.  The  margins  of  the  peritoneum  are  fixed  to 
the  edges  of  the  muscles  in  the  abdominal  incision  with  one  or  two 
silk  or  catgut  stitches  on  either  side,  near  the  middle.  The  anterior 
wall  of  the  stomach,  near  the  fundus,  is  then  seized  with  two  fingers, 
and  drawn  out  of  the  wound  in  a  cone-shaped  process  about  one  and 
one-half  inches  long  and  a  silk  sling  suture  passed  through  its  apex 
to  serve  as  a  tractor.  The  base  of  this  process  of  the  stomach  wall  is- 
fixed  all  around  to  the  edges  of  the  incision  in  the  abdomen  with  a 
continuous  silk  stitch.  This  stitch  should  include  the  serous  and  mus- 
cular coats  of  the  stomach  and  the  edges  of  the  parietal  peritoneum 


234 


ABDOMEN  AND  BACK. 


and  transversalis  fascia  and  deep  muscular  layer  in  the  abdominal  in- 
cision. They  do  not  pass  through  the  skin  nor  should  they  pass 
through  the  entire  thickness  of  the  stomach  wall.  After  this  step  of 
the  operation  has  been  completed  a  second  short  incision  about  three- 
fourths  inch  long  is  made  through  the  integument,  about  one  inch 
above  and  parallel  with  the  first  incision  and  just  beyond  the  free 
border  of  the  ribs.  The  bridge  of  integument  that  intervenes  between 
this  and  the  first  incision  is  then  raised  bluntly  with  the  handle  of  the 


Fig.  97.  —  Gastrostomy  (Ssabanajew- 
Frum-.k).  Cone-shaped  process  of  the 
anterior  wall  of  the  stomach  (8)  drawn 
out  through  abdominal  incision  with  a 
silk  tractor  passed  through  its  apex, 
its  base  sutured  all  around  to  the  edges 
of  the  parietal  peritoneum  and  trans- 
versalis fascia,  etc. 


Fig.  98.  —  Gastrostomy  (Ssabanajew- 
Franck).  Apex  of  cone-shaped  process 
(AS)  sutured  to  the  edges  of  second 
incision  over  the  ribs. 


knife,  and,  with  the  silk  sling  as  a  tractor,  the  apex  of  the  cone-shaped 
process  of  the  stomach  wall  is  drawn  through  into  the  second  small 
incision,  where  it  is  fixed  with  about  four  interupted  silk  sutures. 
The  edges  of  the  skin  corresponding  to  the  first  incision  are  finally 
approximated  with  several  interrupted  silk-worm  gut  sutures,  the 
conical  process  of  the  stomach  wall  being  thus  buried  underneath  the 
bridge  of  tissue  between  the  two  incisions.  After  the  apex  of  the 
cone-shaped  process  of  the  stomach  has  been  sutured  to  the  second 


OPERATIONS  UPON  THE  STOMACH.  235 

small  incision,  it  may  be  opened  and  a  tube  introduced  for  the  pur- 
pose of  feeding.  A  fistulous  tract  about  two  inches  long,  leading  into 
the  stomach,  is  the  result. 

Witzel's  Method,  also  a  very  satisfactory  operation.  An  in- 
cision (Fenger)  about  two  inches  long  is  made  through  the  integu- 
ment, aponeurosis,  and  muscle  down  to  the  parietal  peritoneum, 
which  layer  is  then  picked  up  with  toothed  forceps  and  incised. 

Instead  of  cutting  through  the  muscles  of  the  abdominal  wall 
one  may,  after  the  aponeurotic  layer  (sheath  of  the  rectus)  has  been 
■exposed  and  divided,  separate  bluntly  between  the  fleshy  fibers  of 
the  several  muscles,  between  those  of  the  rectus  in  a  vertical  direc- 
tion and  those  of  the  transversalis  in  a  transverse  direction;  the 
muscles,  having  been  thus  separated,  are  drawn  apart  with  broad 
retractors,  and  the  peritoneum  incised  for  a  length  corresponding 
to  the  length  of  the  incision  in  the  integument. 

It  is  probably  just  as  well  in  most  cases  to  cut  the  muscles,  as 
the  separation  between  the  fibers  adds  to  the  difficulty  of  the  opera- 
tion and  consumes  time,  all  to  little  or  no  purpose. 

Instead  of  the  Fenger  incision  as  described  above  one  may  make 
a  vertical  incision  (Mikulicz),  4  to  5  cm.  long,  just  to  the  left  of  the 
middle  line,  passing  through  the  inner  edge  of  the  rectus  muscle  and 
located  midway  between  the  ensiform  process  and  the  umbilicus. 

Whichever  incision  is  employed,  after  the  abdomen  has  been 
opened  the  parietal  peritoneum  is  fixed  to  the  edges  of  the  incision 
with  one  or  two  catgut  stitches  on  each  side  to  prevent  its  retrac- 
tion. These  stitches  fix  the  parietal  peritoneum  to  the  transversalis 
fascia  and  the  deeper  layer  of  muscles,  but  do  not  include  the  skin. 

Two  fingers  are  now  introduced  into  the  abdomen,  and  the  ante- 
rior wall  of  the  stomach  seized  and  drawn  out  of  the  wound  and 
surrounded  with  aseptic  gauze  pads,  so  that  the  succeeding  steps  of 
the  operation  may  be  done  extraperitoneally. 

A  No.  25  F.  soft  rubber  catheter  is  placed  upon  the  surface  of 
the  stomach  so  that  it  is  directed  obliquely  downward  and  toward 
the  left,  and  in  this  position  it  is  fixed  with  four  interrupted  silk 
sutures,  which  pick  up  the  wall  of  the  stomach  on  either  side  of  the 
catheter,  each  taking  a  good,  broad  bite,  but  not  penetrating  through 
the  entire  thickness  of  the  wall  of  the  stomach.  In  this  way  the 
stomach  wall  is  raised  in  a  fold,  or  plait,  upon  each  side  of  the  tube; 
so  that  when  the  sutures  are  tied  these  two  folds  meet  and  completely 
bury  the  tube.    Corresponding  to  the  end  of  the  catheter  a  very  small 


236 


ABDOMEN  AND  BACK. 


opening  is  now  made  in  the  stomach  wall  with  the  point  of  the  knife, 
and  through  this  the  end  of  the  catheter  is  pushed  so  that  about  three 
inches  of  its  length  is  within  the  stomach.  The  opening  in  the  stom- 
ach should  be  so  small  that  the  tube  will  be  a  tight  fit.  The  free  end 
of  the  tube  is  closed  with  a  ligature  or  forceps  to  prevent  the  escape 
of  stomach  contents.  The  four  sutures  which  have  been  introduced 
across  the  tube  into  the  stomach  wall  are  now  tied,  and  thus  the  tube 
is  imbedded  between  the  two  folds,  which  form  a  canal  about  two 
inches  long  containing  the  tube.  A  sufficient  number  of  additional 
silk  sutures  should  be  introduced  to  secure  the  accurate  coaptation 


Fig.  99.  —  Gastrostomy  (Witzel).  The 
end  of  the  tube  is  passed  through  a 
small  incision  into  the  stomach,  the 
wall  of  the  stomach  being  raised  up 
upon  each  side  of  the  tube  and  sutures 
introduced. 


Fig.  100.— Gastrostomy  (Witzel).  The 
sutures  tied,  thus  uniting  the  folds  cf 
the  stomach  to  each  othtr  and  burying 
the  tube. 


of  the  two  folds  of  the  stomach  wall  over  the  tube,  and  at  the  point 
where  the  end  of  the  tube  enters  the  stomach  the  sutures  should  be 
extended  a  sufficient  distance  beyond  to  insure  against  leakage  from 
the  stomach  around  the  tube.  That  part  of  the  stomach  wall  under- 
neath which  the  tube  is  buried  and  that  immediately  adjacent  to  the 
catheter  as  it  emerges  from  the  canal  formed  by  the  plaiting  of  the 
wall  of  the  stomach  should  now  be  joined  with  interrupted  silk 
sutures  to  the  edges  of  the  parietal  peritoneum  and  transversalis 
fascia  upon  either  side  of  the  abdominal  incision;  these  sutures 
should  take  a  good,  broad  bite  in  the  wall  of  the  stomach,  but  should 
not  pass  through  its  entire  thickness;    they  serve  to  fix  that  part  of 


OPERATIONS  UPON  THE  STOMACH.  237 

the  wall  of  the  stomach  which  is  immediately  adjacent  to  the  tube  to 
the  parietal  peritoneum. 

The  abdominal  incision  is  then  closed,  except  for  a  small  portion 
above,  just  sufficient  to  allow  the  catheter  to  emerge,  with  several 
interrupted  silk-worm  gut  sutures,  each  passing  through  all  the 
layers  of  the  abdomen,  including  the  parietal  peritoneum. 

G-astrorrhaphy. — Suture  of  the  wall  of  the  stomach  for  perfora- 
tion, stab,  or  gunshot  wound. 

An  incision  is  made  in  the  middle  line,  through  the  linea  alba, 
and  the  stomach  exposed. 

If  the  wound  in  the  stomach  is  small,  it  may  be  closed  with  a 
single  row  of  interrupted  Lembert  sutures  of  fine  silk.  These  should 
take  a  good,  broad  bite  in  the  wall  of  the  stomach,  and  should  in- 
clude the  serous  and  muscular  coats  only;  they  should  not  pierce 
the  entire  thickness  of  the  wall  of  the  stomach  or  enter  the  mucous 
membrane  layer. 

If  the  wound  in  the  stomach  is  large,  this  first  row  of  inter- 
rupted Lembert  sutures  may  be  reinforced  by  a  second  continuous 
Lembert  stitch,  which  will  positively  insure  the  accurate  approxi- 
mation of  the  serous  surfaces  and  bury  the  first  row  of  sutures. 

Before  applying  the  sutures  the  surface  of  the  stomach  imme- 
diately adjacent  to  the  wound  should  be  swabbed  with  a  wet  bichlo- 
ride pad.  If  the  peritoneum  has  become  soiled  by  escaping  stomach 
contents,  it  is  well  to  thoroughly  wash  out  the  abdominal  cavity  with 
salt  solution  after  the  opening  in  the  stomach  has  been  closed. 

Pylorectomy.  —  Eesection  of  the  pyloric  end  of  the  stomach; 
adapted  to  early  cases  of  malignant  disease  of  this  part  of  the  stom- 
ach where  the  neighboring  organs,  especially  the  pancreas  and  liver, 
are  not  involved.  The  stomach,  immediately  preceding  the  opera- 
tion and  after  the  patient  has  been  anassthetized,  should  be  washed 
out  through  a  stomach  tube. 

The  incision  is  placed  in  the  middle  line  and  should  be  suffi- 
ciently large,  10  to  15  cm.,  extending  from  the  ensiform  process 
down  to  the  umbilicus  or  beyond  this  point.  The  pyloric  end  of  the 
stomach  is  drawn  into  the  wound  and  well  surrounded  with  gauze 
pads  so  arranged  as  to  protect  the  abdominal  cavity  during  the  op- 
eration, and  the  left  lobe  of  the  liver  is  held  up  out  of  the  way  by 
an  assistant. 

Billroth's  Method. — The  first  step  in  the  operation  is  the 
isolation  of  the  pylorus  (diseased  part,  which  is  to  be  excised)  from 


238 


ABDOMEN  AND  BACK. 


the  greater  omentum  (transverse  colon)  below  and  from  the  lesser 
omentum  above.  With  a  blunt-pointed  ligature  carrier,  armed  with 
catgut  or  fine  silk,  the  greater  and  lesser  omenta,  corresponding  to 
the  diseased  pylorus,  are  transfixed  and  tied  off  in  sections;  the  greater 


Fig.  101. — Pylorectomy.  Anterior  edge  cf  the  liver  is  lifted  up;  the  lesser 
and  greater  omenta  are  shown.  The  lesser  and  greater  omenta,  correspond- 
ing to  the  portion  of  the  stomach  that  is  to  be  excised,  have  been  ligated  in 
sections.  The  dotted  lines  indicate  the  line  of  section  through  the  stomach 
and  omenta.  Instead  of  being  applied  as  represented  in  this  picture,  the 
ligatures  may  be  placed  double  and  the  line  of  incision  carried  between  them. 


and  lesser  omenta  are  then  cut  away  from  the  pylorus,  cutting  with 
the  scissors  between  the  ligatures  and  the  pylorus.  Each  ligature 
should  include  one  to  one  and  one-half  inches  of  the  omentum.  In- 
stead of  a  ligature  carrier  a  sharp-nosed  artery  forceps  may  be  used 


OPERATIONS  UPON  THE  STOMACH.  23£ 

to  pass  the  ligatures.  One  should  be  mindful  of  the  location  of  the' 
common  bile-duct  and  the  portal  vein  in  the  free  edge  of  the  lesser 
omentum. 

After  the  pylorus  (tumor)  has  been  thus  entirely  freed  from  it& 
omental  attachment  above  and  below,  it  may  be  drawn  pretty  well 
out  through  the  abdominal  incision,  so  that  the  operation  may  be- 
continued  with  more  ease. 

Before  excising  the  pylorus  (tumor)  compression  clamps  are  ap- 
plied about  the  stomach  and  duodenum  close  to  the  tumor;  ordinary 
long-limbed  artery  forceps  will  answer  for  this  purpose.  Two  are- 
applied  to  the  stomach,  close  to  the  tumor,  one  reaching  from  the 
lesser  curvature  and  one  from  the  greater  curvature,  and  one  is 
placed  about  the  duodenum,  also  rather  close  to  the  tumor.  The 
stomach  is  then  seized  by  an  assistant,  who  compresses  it  between 
the  fingers  of  both  hands,  grasping  it  just  beyond  the  place  where 
the  clamps  are  applied  in  order  to  prevent  the  escape  of  the  stomach 
contents  when  it  is  cut,  and  then  the  operator,  with  a  sharp  scissors, 
cuts  across  the  stomach  from  above  downward,  between  the  fingers 
of  the  assistant  and  the  clamps. 

The  stump  of  the  pylorus  is  now  enveloped  in  a  compress  and 
turned  to  one  side,  the  clamps  preventing  any  leakage.  The  hemor- 
rhage from  the  cut  edge  of  the  stomach  is  controlled  by  catching 
the  bleeding  points  with  forceps;  any  spurting  arterial  points  should 
be  ligated  with  fine  silk;  the  hemorrhage  from  the  divided  veins- 
ceases  when  the  suture  is  applied. 

The  opening  in  the  stomach  is  closed,  commencing  above  and 
working  downward  toward  the  greater  curvature,  first  with  a  con- 
tinuous stitch  of  silk,  which  includes  all  the  coats  of  the  stomach 
and  which  is  applied  with  a  long,  straight  needle.  Each  loop  of  the 
suture  is  drawn  fairly  tight.  The  lower  part  of  the  opening  in  the 
stomach  is  left  unclosed  for  a  sufficient  length  to  allow  the  inser- 
tion, later,  of  the  stump  of  the  duodenum.  A  second  continuous 
Lembert  stitch  is  then  introduced,  which  inverts  and  buries  the  first 
line  of  suture.  Through  the  opening  left  below  some  strips  of  iodo- 
form gauze  are  packed  into  the  stomach  to  prevent  leakage,  and  then,, 
enveloped  in  a  compress,  it  is  temporarily  laid  aside. 

The  attention  of  the  operator  is  now  directed  to  the  duodenum. 
Its  contents  are  stripped  along  with  the  finger,  and  a  compressor 
applied,  or  it  may  be  surrounded  by  a  strip  of  gauze  which  is  tied 
moderately  tight  to  prevent  the  escape  of  its  contents  when  it  is. 


24:0 


ABDOMEN  AND  BACK. 


cut.  If  the  gauze  strip  is  used,  it  may  be  carried  around  the  duo- 
denum in  the  mouth  of  a  sharp-nosed  artery  forceps,  which  is  thrust 
through  its  mesentery.  Instead  of  a  compressor  or  strip  of  gauze  the 
duodenum  may  be  compressed  between  the  fingers  of  an  assistant; 
but  the  assistant's  fingers  occupy  considerable  space,  and  may  thus 
interfere  with  the  work  of  the  operator. 

The  duodenum  is  divided  a  short  distance  beyond  the  clamp 
which  had  been  applied  to  it,  and  the  resection  of  the  pylorus  is 
thus  accomplished.  Any  escaping  contents  from  the  end  of  the  duo- 
denum should  be  caught  upon  a  gauze  pad,  and  the  edge  of  the 
duodenum  wiped  off  with  a  wad  of  wet  bichloride  gauze. 


Fig.  102. — Pylorectomy  (Billroth).  Dotted  lines  indicate  lines  of  section 
in  excising  diseased  pylorus.  XXX  represent  diseased  portion  that  is  to  be 
excised. 


The  protecting  gauze  pads  are  now  renewed,  the  gauze  removed 
from  the  opening  remaining  in  the  stomach,  and  the  end  of  the 
duodenum  sutured  into  this  opening.  There  is  first  applied,  with 
a  curved  surgeon's  needle,  a  continuous  silk  suture;  this  should  be 
applied  from  within  the  gut  so  that  the  raw  edges  present  toward 
the  interior  of  the  gut.  This  line  of  suture  should  include  all  the 
coats,  take  a  good  bite,  and  be  drawn  fairly  tight.  When  this  suture 
is  completed,  it  is  reinforced  by  a  second  row  of  outside  sutures, 
uninterrupted  and  of  fine  silk,  which  includes  only  the  serous  and 
muscular  coats  and  buries  the  first  line  of  suture.  Special  care 
should  be  taken  to  secure  the  point  where  the  stomach  suture  meets 
the  suture  that  unites  the  stomach  and  the  duodenum. 


OPERATIONS  UPON  THE  STOMACH. 


241 


"With  the  Mukphy  Button. — The  junction  of  the  end  of  the 
duodenum  and  the  stomach  may  he  accomplished  hy  means  of  a 
Murphy  hutton.  The  opening  left  in  the  end  of  the  stomach,  after 
the  pylorus  has  heen  cut  away,  is  closed  throughout  its  entire  length, 
and  a  junction  then  made  between  the  stump  of  the  duodenum  and 
a  new  opening,  which  is  made  in  the  posterior  wall  of  the  stomach 
about  one  inch  away  from  its  sutured  edge. 

The  end  of  the  stomach  and  the  end  of  the  duodenum  may  he 
both  closed  completely  by  inversion  and  suture,  and  a  regular  gastro- 
jejunostomy then  performed  with  or  without  a  Murphy  button  or 
with  McGraw's  rubber  suture  or  with  the  Laplace  or  O'Hara  for- 
ceps, etc. 


Fig.  103. — Pylorectomy  (Billroth).     Diseased  portion  has  been  excised  and 
the  end  of  the  duodenum  sutured  to  the  end  of  the  stomach. 


In  excising  the  diseased  pylorus  one  should  not  go  too  far  along 
on  the  duodenum,  as  the  second  part  of  this  segment  of  the  gut  is 
only  partly  invested  with  peritoneum,  and  is  therefore  unfavorable 
for  union  with  the  stomach. 

Method  of  Kochek  (Eesection"  of  the  Pylorus,  with  Gastro- 
duodenostomt). — Marked  success  in  Kocher's  hands. 

The  pyloric  tumor  is  exposed  through  a  long  median  incision 
and  then  isolated  from  its  omental  attachments  as  described  above. 
After  the  pyloric  tumor  has  been  thus  isolated  compresses  are  packed 
about  it  to  protect  the  abdominal  cavity,  and  clamps  applied:  ordi- 
nary long-limbed  artery  clamps.  Upon  the  stomach  side  of  the  tu- 
mor— in  order  to  include  the  whole  width  of  the  stomach — two 
clamps  are  necessary:    one  reaching  from  above  downward  and  the 


242  ABDOMEN  AND  BACK. 

other  from  below.  Upon  the  duodenum,  to  the  distal  side  of  the 
tumor,  a  clamp  is  likewise  applied;  parallel  with  this,  hut  farther 
along,  a  second  clamp  is  applied  to  the  duodenum. 

The  duodenum  is  now  divided  with  sharp  scissors,  between  the 
two  clamps,  but  not  too  close  to  the  distal  clamp,  in  order  to  leave 
room  enough  for  necessary  manipulation  in  suturing,  etc.  The 
cut  edge  of  the  duodenum,  protruding  between  the  limbs  of  the  clamp, 
is  wiped  clean  of  intestinal  contents  with  a  wet  bichloride  pad  and 
then  enveloped  in  sterile  gauze,  and  with  the  clamp  still  applied  it 
is  turned  to  the  right  and  held  against  the  right  edge  of  the  abdom- 
inal incision  by  an  assistant.  The  clamp  which  compresses  the  stump 
of  the  duodenum  should  not  be  too  tight,  although  Kocher  says  that 
it  does  not  damage  the  gut,  that  the  gut  still  bleeds  from  its  edge 
after  the  clamp  is  removed. 

We  then  turn  our  attention  to  the  stomach.  The  stomach  is 
seized  between  the  fingers  of  both  hands  by  an  assistant,  and  the 
pyloric  portion  cut  away  in  a  direction  from  above  downward,  be- 
tween the  clamps  and  the  assistant's  fingers,  and  removed.  The 
tumor  mass,  being  tightly  clamped  at  both  ends,  when  cut  away  does 
not  leak.  Bleeding,  spurting  points  in  the  cut  edge  of  the  stomach 
are  clamped  and  tied  with  fine  silk;  oozing  and  venous  hemorrhage 
stop  when  the  suture  is  applied. 

The  margins  of  the  wound  in  the  stomach  are  now  wiped  off 
with  a  wet  bichloride  pad  and  brought  together  throughout  their 
entire  length  with  a  continuous  silk  stitch  in  a  long,  straight  needle. 
This  stitch  includes  all  the  coats,  and  takes  a  good  bite;  this  sutured 
edge  is  then  again  wiped  off  with  a  wet  bichloride  pad  and  a  fine, 
continuous  Lembert  stitch  is  applied,  inverting  the  raw  edges  of  the 
stomach  wound  and  completely  burying  the  first  suture. 

The  protecting  abdominal  pads  are  now  again  renewed,  and  we 
may  proceed  with  the  last  step  of  the  operation:  the  union  of  the 
stump  of  the  duodenum  to  the  posterior  wall  of  the  stomach. 

The  assistant,  still  holding  the  stomach,  directs  its  sutured  end 
forward  out  of  the  wound;  so  that  its  posterior  surface  looks  toward 
the  duodenum,  which  is  held  over  against  the  right  edge  of  the 
abdominal  incision.  The  cut  end  of  the  duodenum,  with  the  com- 
pressor clamp  still  applied,  is  joined  to  the  posterior  wall  of  the 
stomach  by  a  continuous  stitch  of  fine  silk,  which  is  applied  with 
a  cambric  needle  and  which  corresponds  to  the  posterior  half  of  the 
circumference  of  the  duodenum  as  it  protrudes  from  the  clamp.    This 


OPERATIONS  UPON  THE  STOMACH. 


243 


suture  catches  the  duodenum  just  beyond  its  cut  edge.  This  stitch 
does  not  pass  through  the  entire  thickness  of  the  duodenum,  but 
catches  only  the  serous  and  muscular  coats  of  the  duodenum  and 
the  corresponding  coats  of  the  stomach.  It  forms  the  posterior  half 
of  the  "outside  serous  ring  suture."  This  needle,  still  threaded,  is 
then  laid  aside  until  it  is  wanted  later  to  complete  this  "outside 
serous  ring  suture."  The  end  of  the  duodenum  is  sutured  to  the 
posterior  wall  of  the  stomach  about  one  inch  distant  from  the  sutured 
edge  of  the  latter. 


Fig.  104. — Pylorectomy  (Kocher).  The  end  of  the  duodenum  has  been 
sutured  to  the  edge  of  the  opening  made  in  the  posterior  wall  of  the  stomach 
with  a  continuous  non-penetrating  stitch. 


The  clamp  is  now  removed  from  the  duodenum,  the  hemorrhage 
controlled,  and  any  escaping  contents  sponged  away,  finally  wiping 
the  margin  with  a  wet  bichloride  pad.  An  opening  is  then  made  in 
the  stomach  of  a  size  to  correspond  with  the  end  of  the  duodenum. 
This  should  be  placed  one-fourth  inch  from  the  line  of  suture  by 
which  the  duodenum  is  already  joined  to  the  wall  of  the  stomach. 
The  edge  of  the  duodenum  stump  is  then  sutured  all  around  to  the 
edges  of  the  opening  in  the  stomach,  with  a  curved  needle  and  silk, 
this  being  a  continuous  stitch  applied  from  within,  and  including  the 
whole  thickness  of  the  wall  of  each  organ  and  taking  a  good  bite,  so 
that  the  raw  edges  of  the  parts  look  inward  toward  the  lumen  of  the 
gut.  When  the  parts  have  been  thus  united  all  around,  the  original 
needle  is  again  taken  in  hand,  and  the  Lembert  suture  which  forms 


244  ABDOMEN  AND  BACK. 

the  anterior  half  of  the  "outside  serous  ring"  applied  and  the  union 
is  complete.  Before  joining  the  serous  coats  the  parts  should  be 
swabbed  with  a  bichloride  pad. 

The  protecting  pads  are  now  removed  and  the  abdominal  incision 
closed.  With  a  continuous  catgut  stitch  the  edges  of  the  peritoneum 
are  coapted,  and  with  several  interrupted  silk-worm  gut  sutures — 
which  pass  through  the  skin,  muscle,  and  aponeurosis — the  closure 
of  the  abdominal  wound  is  completed. 

Gastrectomy. — Extirpation  of  the  entire  stomach.  First  case 
by  Schlatter,  1897.  A  healthy  heart  is  essential  to  the  success  of 
this  operation.  The  operating  room  should  be  kept  warm  and  the 
patient  dressed  in  flannel  garments  to  prevent  as  much  as  possible 
loss  of  body-heat  by  radiation.  The  stomach  should  be  washed  out 
immediately  before  the  operation  is  commenced,  after  the  patient  has 
been  anesthetized. 

The  incision  is  best  made  in  the  linea  alba,  and  must  be  liberal, 
— from  six  to  seven  inches  in  length, — reaching  from  the  ensiform 
process  to  the  umbilicus  or  even  beyond  this  point. 

After  the  abdomen  has  been  opened  the  stomach  is  recognized 
and  examined,  and  search  made  for  secondary  deposits  in  the  liver 
and  adjoining  lymphatic  glands.  In  many  cases  the  stomach  can  be 
drawn  almost  entirely  out  of  the  abdomen,  and  thus  the  performance 
of  the  operation  is  facilitated. 

The  first  step  consists  in  the  isolation  of  the  stomach,  freeing 
it  from  the  greater  and  lesser  omenta  and  from  its  attachment  to 
the  spleen:    gastro-splenic  omentum. 

Commencing  at  the  pyloric  end  of  the  stomach,  the  omenta 
are  tied  off  in  sections, — first  the  lesser  and  then  the  greater  omen- 
tum,— each  ligature  being  tied  double  and  including  about  one  and 
one-half  inches  of  the  omentum.  In  ligating  the  lesser  omentum 
the  liver  must  be  drawn  up  out  of  the  way  and  the  stomach  pulled 
down.  The  presence  of  the  common  bile-duct  between  the  layers  of 
the  lesser  omentum,  near  its  free  right  border,  should  not  be  for- 
gotten. After  the  lesser  and  greater  omenta  have  been  ligated  as 
far  as  the  middle  of  the  stomach  and  divided,  the  section  may  be 
made  between  the  pylorus  and  duodenum,  in  order  that  the  stomach 
may  the  better  be  drawn  down,  so  as  to  make  the  isolation  of  its 
cardiac  end  less  difficult,  or  else  one  may  wait  until  the  whole  length 
of  the  lesser  and  greater  omenta  has  been  ligated  and  cut  away  from 
the  stomach  before  the  division  is  made  at  its  duodenal  end.     The 


OPERATIONS  UPON  THE  STOMACH.  245 

division  of  the  omentum  should  be  made  between  the  double  ligatures 
with  the  scissors,  cutting  from  one  ligature  hole  into  the  next. 

After  the  stomach  has  been  freed  of  its  omentum,  along  the 
lesser  and  greater  curvatures,  we  are  ready  for  the  next  step  of  the 
operation:  the  removal  of  the  stomach.  The  stomach  is  divided 
first  at  its  pyloric  end,  if  this  has  not  already  been  done.  An  intes- 
tinal clamp  is  placed  about  the  duodenum,  about  one  and  one-half 
inches  from  the  pylorus,  and  a  clamp  about  the  pyloric  end  of  the 
stomach,  and  between  these'  the  intestine  is  divided  with  the  scissors. 
Any  escaping  contents  are  caught  upon  a  pad,  and  the  end  of  the 
duodenum,  sterilized  and  wrapped  in  gauze,  and  with  the  compressor 
still  applied,  is  dropped  temporarily  into  the  abdomen. 

A  ligature  is  then  thrown  around  the  gastro-splenic  omentum; 
this  is  the  peritoneal  fold  that  reaches  from  the  fundus  of  the  stom- 
ach to  the  spleen,  and  through  it  the  vasa  brevia  pass  to  the  stomach. 

This  ligature  is  applied  double,  that  we  may  divide  between 
them.  Special  pains  should  be  taken  to  secure  the  vessels  in  the 
gastro-splenic  omentum,  leaving  the  ligature  long  that  the  pedicle 
may  be  drawn  forward,  so  that,  if  necessary,  the  vessels  may  be 
secured  with  additional  ligatures. 

To  reach  the  oesophagus  the  stomach  must  be  pulled  well  down- 
ward. An  intestinal  compressor  is  placed  about  the  oesophagus  a 
short  distance  below  the  diaphragm,  and  a  clamp  about  the  oesoph- 
ageal end  of  the  stomach,  and  then  between  these  the  oesophagus  is 
divided  with  the  scissors.    The  stomach  is  thus  removed. 

After  the  stomach  has  been  excised  it  becomes  necessary  to 
restore  the  continuity  of  the  alimentary  canal,  either  by  joining  the 
end  of  the  duodenum  to  the  oesophagus,  oesophago-duodenostomy, 
or  else  by  inserting  the  end  of  the  oesophagus  into  the  jejunum, 
oesophago-enterostomy. 

In  most  cases  the  oesophagus  can  be  drawn  down  and  the  duo- 
denum sufficiently  mobilized  to  allow  of  its  being  brought  up  into 
apposition  with  the  end  of  the  oesophagus  without  tension.  In  this 
case  the  parts  may  be  joined  with  a  Murphy  button  No.  3  (see 
"End-to-End  Anastomosis").  After  the  button  has  been  inserted 
the  compression  clamps  may  be  removed  from  the  duodenum  and 
oesophagus,  and  a  row  of  outside  Lembert  sutures  applied  to  make 
the  junction  still  more  secure.  These  sutures  include  the  serous 
and  muscular  coats,  but  do  not  pass  through  the  mucous  membrane. 

If  unable  to  approximate  the  parts  as  described,  the  end  of 


246 


ABDOMEN  AND  BACK. 


the  duodenum  may  be  inverted  and  closed  with  a  double  row  of 
sutures  and  an  cesophago-enterostomy  done,  the  end  of  the  cesoph- 


Fig.  105.— Gastrectomy.  0E8,  stump  of  oesophagus;  D,  end  of  the  duo- 
denum. Dotted  lines  indicate  the  excised  stomach.  The  small  intestine 
(jejunum)  has  been  drawn  up  into  apposition  with  the  stump  of  the  oesoph- 
agus, as  in  cesophago-enterostomy. 

agus  being  sutured  into  an  opening  which  is  made  in  the  small  in- 
testine. The  upper  part  of  the  jejunum  is  sought  in  the  upper  back 
part  of  the  abdominal  cavity, — to  the  left  of  the  body  of  the  second 


SURGICAL  ANATOMY  OF  THE  SMALL  INTESTINE.  247 

lumbar  vertebra, — and  a  coil  of  gut  about  eighteen  inches  beyond 
this  point  selected.  A  segment  of  this  coil  of  gut  about  six  inches 
long  is  tied  off  with  tapes,  first  one  and  then  the  other,  after  the 
contents  of  the  segment  have  been  stripped  along  with  the  fingers. 
This  segment  of  gut  is  then  brought  up,  around  the  transverse  colon, 
into  apposition  with  the  end  of  the  oesophagus. 

The  posterior  half  of  the  circumference  of  the  end  of  the  oesoph- 
agus is  sutured  to  the  wall  of  the  coil  of  gut  with  a  row  of  continuous 
Lembert  sutures.  These  sutures  secure  the  wall  of  the  oesophagus 
about  one-fourth  inch  beyond  its  cut  edge,  and  include  the  serous 
and  muscular  coats,  but  not  the  mucous.  This  needle  is  then  dis- 
carded temporarily,  and  an  incision  is  made  in  the  gut  corresponding 
in  length  to  the  size  of  the  opening  in  the  oesophagus.  The  edge  of 
this  opening  in  the  gut  is  sutured  to  the  edge  of  the  oesophagus  all 
around  with  a  continuous  silk  stitch  that  includes  all  the  layers. 
When  this  suture  has  been  completed  and  the  end  of  the  oesophagus 
thus  securely  fixed  to  the  opening  in  the  intestine,  the  first  needle, 
that  with  which  the  posterior  half  of  the  end  of  the  oesophagus  was 
joined  to  the  gut,  is  again  taken  in  hand  and  the  anterior  half  of 
the  "outside  serous  ring"  suture  applied.  It  is  well  to  use  silk  ex- 
clusively for  both  sutures  and  ligatures  in  this  operation.  The  ab- 
dominal wound  is  closed  without  drainage. 

During  the  course  of  the  operation  the  solar  plexus  may  be 
considerably  molested,  and  at  the  time  that  the  oesophagus  is  severed 
both  pneumogastric  nerves  are  also  divided.  The  shock  is  therefore 
apt  to  be  marked,  and  should  be  counteracted  by  avoiding  as  much  as 
possible  loss  of  body-heat  and  by  administering  proper  stimulation. 
The  division  of  the  pneumogastrics  leads  to  disturbance  of  the 
heart's  action;  it  becomes  very  greatly  accelerated,  and  an  attempt 
should  be  made  to  regulate  this,  probably  with  proper  doses  of  digi- 
talis hypodermically.  For  the  first  few  days  the  patient  is  nourished 
per  rectum;  after  forty-eight  hours  fluids  may  be  given  per  mouth, 
first  small  quantities  of  water  and  then  broth,  milk,  etc.,  may  be 
added.  At  the  end  of  a  week  a  moderate  amount  of  solid  food  may 
be  taken  through  the  mouth. 

THE  SMALL  INTESTINE. 

The  Surgical  Anatomy  of  the  Small  Intestine.  The  Duodenum 
is  the  first  part  of  the  small  intestine.  It  is  about  ten  inches  long 
and  commences  at  the  pyloric  end  of  the  stomach  and  ends  at  the 


248  ABDOMEN  AND  BACK. 

jejunum.  Its  wall  is  moderately  thick.  It  is  usually  described  as 
consisting  of  three  parts. 

The  first,  or  ascending,  part  is  freely  movable,  continuous  with 
the  pylorus,  and  entirely  invested  by  peritoneum.  It  passes  from 
the  pyloric  end  of  the  stomach  upward  and  backward  toward  the 
right  as  high  as  the  level  of  the  twelfth  dorsal  vertebra;  it  reaches 
close  to  the  under  surface  of  the  liver,  with  which  it  is  connected 
by  the  so-called  ligamentum  hepatico-duodenale.  This  ligament  is 
simply  the  free,  thickened,  right  edge  of  the  lesser  omentum:  liga- 
mentum gastro-hepaticum.  Between  the  layers  of  this  lesser  omen- 
tum are  the  hepatic  artery,  portal  vein,  and  common  bile-duct,  the 
artery  ascending  to  the  liver,  and  the  duct  and  vein  descending  be- 
hind this  first  part  of  the  duodenum.  Between  the  layers  of  the 
lesser  omentum  the  artery  lies  to  the  left,  the  duct  to  the  right, 
and  the  vein  between  and  behind  both. 

The  duodenum  then  makes  a  turn  downward  along  the  right 
side  of  the  first  and  second  lumbar  vertebrae,  lying  upon  the  front 
of  the  right  kidney,  with  the  head  of  the  pancreas  to  the  left  (i.e., 
internal  to  this  part  of  the  duodenum).  This  is  called  the  second 
part  of  the  duodenum.  It  differs  from  the  first  part  in  being  fixed 
to  the  posterior  wall  of  the  abdomen  and  in  not  being  completely 
surrounded  by  peritoneum,  but  simply  covered  by  the  peritoneum 
upon  its  front  surface,  and  therefore  when  we  look  for  this  part 
of  the  duodenum,  after  reflecting  the  transverse  colon  and  the  great 
omentum  upward,  it  is  not  to  be  seen,  and  is  only  exposed  to  view 
after  the  peritoneum  which  covers  its  anterior  surface  has  been  cut 
through.  The  common  bile-duct  and  the  pancreatic  duct  open  into 
the  second  part  of  the  duodenum,  between  it  and  the  head  of  the 
pancreas.  These  ducts  pass  obliquely  through  the  wall  of  the  duo- 
denum, and  join  with  each  other,  before  entering  the  gut,  through 
a  single  common  orifice,  which  is  found  upon  the  inner  wall  of  the 
duodenum  in  the  center  of  a  papilla.  A  sound  may  be  passed  from 
this  part  of  the  duodenum  into  the  common  duct  or  into  the  pan- 
creatic duct. 

Between  the  head  of  the  pancreas  and  this  part  of  the  duo- 
denum in  the  injected  cadaver  there  may  be  seen  the  anastomosis 
between  the  superior  and  inferior  pancreatico-duodenalis  arteries: 
branches  derived  from  the  hepatic  and  superior  mesenteric,  respect- 
ively. 

At  the  level  of  the  third  lumbar  vertebra  the  duodenum  makes 


SURGICAL  ANATOMY  OF  THE  SMALL  INTESTINE.  249 

another  turn,  passing  across  the  hody  of  the  third  lumhar  from  the 
right  to  the  left  side  of  this  vertebra,  and  at  the  same  time  ascend- 
ing to  the  level  of  the  second  lumhar  vertebra.  This  is  known  as 
the  third  part  of  the  duodenum.  The  aorta,  etc.,  lie  behind  this  part 
of  the  duodenum,  and  the  head  of  the  pancreas  lies  above  it. 

Upon  the  left  side  of  the  second  lumbar  vertebra  the  duodenum 
is  fixed  to  the  vertebral  column  by  a  thickened  portion  of  perito- 
neum; this  fold  contains  some  unstriped  muscular  fibers,  and  is 
called  the  suspensory  ligament  of  the  duodenum,  the  ligament  of 
Treitz.  This  third  part  of  the  duodenum  is  also  covered  upon  its 
anterior  surface  only  by  the  peritoneum,  and  is  fixed  by  this  layer 
in  the  back  of  the  abdomen  in  common  with  the  pancreas.  This  por- 
tion of  the  duodenum  is  not  to  be  seen  when  we  examine  this  part 
of  the  abdomen  until  after  the  layer  of  peritoneum  which  covers  its 
anterior  surface  and  conceals  it  from  view  has  been  cut. 

The  whole  duodenum,  in  its  curved  course,  resembles  a  horse- 
shoe in  the  hollow  of  which  the  head  of  the  pancreas  is  received. 

The  second  and  third  parts  of  the  duodenum  are  rather  un- 
favorable parts  for  operation,  on  account  of  their  fixedness  and 
depth  and  the  incompleteness  of  their  peritoneal  covering. 

The  Jejunum  and  Ileum,  about  twenty  feet  long,  make  up 
the  rest  of  the  tube  of  small  intestine,  and  are  the  direct  continua- 
tion of  the  duodenum,  terminating  in  the  caecum  in  the  right  iliac 
fossa. 

Upon  the  left  side  of  the  second  lumbar  vertebra,  where  the 
duodenum  ends  and  the  jejunum  begins,  the  intestinal  canal  becomes 
again  provided  with  a  complete  peritoneal  investment  and  a  long 
mesentery,  and  is  known  as  the  jejunum. 

The  jejunum  forms  about  two-fifths  of  the  length  of  the  small 
intestine,  and  becomes  the  ileum  where  the  valvulas  conniventes, 
which  characterize  its  inner  surface,  cease  to  exist.  It  is  thick  walled 
and  large  in  caliber,  and  therefore  resembles  somewhat  the  large 
intestine;  still,  it  is  readily  distinguished  from  this  part  of  the  gut 
by  the  absence  of  the  longitudinal  stria?  and  appendices  epiploicse  and 
in  not  being  sacculated. 

At  its  commencement,  upon  the  left  side  of  the  second  lumbar 
vertebra,  the  jejunum  seems  to  project  directly  forward,  through  the 
parietal  peritoneum  which  lines  the  back  of  the  abdominal  cavity. 
This  appearance  is  due  to  the  fact  that  the  portion  of  the  gut, 
duodenum,  which  immediately  precedes  the  jejunum,  is  not  pro- 


250  ABDOMEN  AND  BACK. 

vided  with  a  mesentery,  lying  behind  the  peritoneum  and  covered 
by  it  upon  its  anterior  surface  only,  whereas  the  commencement 
of  the  jejunum  and  the  rest  of  the  small  intestine  are  provided 
with  an  investment  of  peritoneum,  which  completely  surrounds  them, 
and  a  mesentery,  which  suspends  them  to  the  back  of  the  abdomen, 
and,  therefore,  where  this  arrangement  commences,  the  gut  appears 
to  project  directly  forward  through  the  peritoneum  from  the  poste- 
rior wall  of  the  abdomen.  The  process  of  peritoneum  that  incloses 
the  first  part  of  the  jejunum  marks  the  commencement  of  the 
mesentery. 

We  can  locate  this  first  portion  of  the  jejunum  by  reflecting 
the  great  omentum,  and  with  it  the  transverse  colon,  upward  out 
of  the  way,  and  then,  passing  the  hand  back  to  the  vertebral  col- 
umn, this  coil  of  intestine  is  found  lying  just  to  the  left  of  the 
body  of  the  second  lumbar  vertebra.  An  attempt  to  draw  this  coil 
of  gut  out  of  the  abdomen  will  show  that  it  is  fixed  within  the  ab- 
domen, and  this  fact  will  serve  to  identify  it  positively. 

The  ileum,  which  is  the  continuation  of  the  jejunum,  consti- 
tutes three-fifths  of  the  length  of  the  small  intestine.  It  becomes 
progressively  smaller  in  caliber  and  thinner  as  we  trace  it  toward  its 
termination  at  the  caecum,  where  its  wall  is  thinnest  and  its  caliber 
narrowest. 

The  jejunum  and  ileum  are  suspended  free  in  the  abdominal 
cavity  arranged  coil  upon  coil,  and  are  provided  with  a  complete 
peritoneal  envelope  and  a  long  mesentery,  through  which  they  are 
attached  to  the  vertebral  column  in  the  back  of  the  abdomen. 

The  Mesentery  is  a  reflection  of  peritoneum  containing  some 
unstriped  muscular  fiber,  fat,  etc.;  it  serves  to  suspend  the  gut  in 
the  abdomen  and  at  the  same  time  supports  the  blood-vessels,  lym- 
phatics, nerves,  etc.,  in  their  course  to  and  from  the  small  intestine. 

The  mesentery  is  fan-shaped.  The  distal  border  is  very  long, 
corresponding  to  the  whole  length  of  the  small  intestine,  to  which 
it  is  attached;  the  proximal  border  is  short  and  is  fixed  to  the  ante- 
rior surface  of  the  vertebral  column,  reaching  from  the  left  side  of  the 
second  lumbar  vertebra,  where  the  duodenum  ends  and  the  jejunum 
commences,  downward,  to  the  right  side  of  the  fifth  lumbar  vertebra; 
its  line  of  attachment  is  thus  oblique  from  the  left  side,  above,  down- 
ward and  to  the  right.  The  vertebral  edge  of  the  mesentery  is 
but  six  inches  long,  whereas  the  distal,  intestinal  edge  is  about 
twenty  feet  long,  and  in  order  to  accomodate  these  two  borders  to 


SURGICAL  ANATOMY  OF  THE  SMALL  INTESTINE.  251 

each  other  the  intestinal  end  of  the  mesentery  is  folded  and  folded 
upon  itself,  making  a  series  of  plaits. 

Where  the  two  layers  of  peritoneum  of  which  the  mesentery  is 
composed  meet  the  intestine,  they  diverge  and  surround  the  intes- 
tine in  a  sling-like  fashion,  the  intestine  being  entirely  invested 
except  for  the  small  "dead"  space  which  corresponds  to  the  separa- 
tion of  the  layers  of  the  mesentery  at  the  so-called  mesenteric  border 
of  the  intestine.  Here  the  mesentery  is  not  applied  directly  to  the 
surface  of  the  intestine,  but  is  separated  from  it,  leaving  a  small 
space — "dead  space" — where  the  serous  layer  does  not  form  part  of 
the  wall  of  the  intestinal  tube. 

The  'Blood-supply  of  the  Small  Intestine  is  furnished  by 
the  superior  mesenteric  artery.  This  vessel  is  given  off  from  the 
anterior  aspect  of  the  aorta,  and  passes  forward  between  the  lower 
border  of  the  pancreas  and  third  part  of  the  duodenum;  it  is  located 
between  the  layers  of  the  mesentery,  and  courses,  in  a  curved  direc- 
tion downward  and  to  the  right,  toward  the  right  iliac  fossa.  The 
superior  mesenteric  is  a  short,  thick  trunk.  From  its  convex  side  it 
gives  off  branches  to  supply  the  whole  length  of  the  small  intestine; 
from  its  concave  side  it  gives  off  branches  to  the  large  intestine,  to 
the  caecum  and  vermiform  appendix,  ascending  colon,  and  transverse 
colon,  finally  anastomosing  with  a  branch  from  the  inferior  mesen- 
teric (see  below).  The  superior  mesenteric  vein  accompanies  the 
artery  and  its  branches,  and  behind  the  pancreas  joins  with  the 
splenic  to  form  the  portal  vein.  The  blood  in  the  portal  vein  is 
derived  from  the  intestine;  before  reaching  the  general  circulation 
it  passes  through  the  liver;  it  leaves  the  liver  through  the  hepatic 
veins,  two  or  three  in  number,  which  empty  into  the  inferior  vena  cava. 

The  branches  of  the  superior  mesenteric,  which  supply  the 
small  intestine,  are  given  off,  as  already  mentioned,  from  the  con- 
vex, left,  side  of  the  artery.  These  branches  do  not  pass  direct  to 
the  intestine,  but  anastomose  with  each  other,  forming  a  series 
of  arches.  From  this  set  of  arches  another  series  of  branches  is 
given  off,  and  thus  this  peculiar  anastomotic  arch  formation  con- 
tinues until  the  intestine  is  almost  reached;  finally  the  individual 
branches  from  the  ultimate  arches  are  distributed  to  the  wall  of 
the  intestine.  They  pass  to  the  intestine  from  between  the  layers 
of  the  mesentery,  where  these  separate  to  envelop  the  intestine — 
that  is,  at  the  mesenteric  border — through  the  so-called  "dead 
space."     After  the  ultimate  vascular  branches  reach  the  wall  of  the 


252  ABDOMEN  AND  BACK. 

gut  they  do  not  communicate  freely  with  each  other,  so  that  each 
segment  of  gut  is  dependent  almost  entirely  upon  one  or  two  def- 
inite vessels  for  its  nutrition  and  integrity.  The  same  arrangement 
holds  good  for  the  ultimate  veins.  Therefore,  if  several  of  these 
ultimate  vascular  branches  are  severed  close  to  the  gut  or  become 
embolized  or  thrombosed,  we  are  apt  to  have,  as  a  result,  gangrene 
of  the  corresponding  segment  of  the  gut.  Wounds  of  the  intestine 
at  the  mesenteric  border  are  unfavorable  for  suture  on  account  of 
the  absence  of  the  serous,  peritoneal  covering,  at  this  part.  Wounds  at 
the  mesenteric  border  of  the  gut  almost  of  necessity  include  division 
of  the  ultimate  intestinal  arteries  and  veins,  and  therefore  interfere 
seriously  with  the  blood-supply  to  the  corresponding  part  of  the 
gut. 

OPERATIONS  UPON  THE  SMALL  INTESTINE. 

Enterorrhaphy. — Suture  of  the  intestine  for  gunshot  and  stab 
wounds  and  for  perforations  due  to  ulceration,  etc. 

These  injuries  are  frequently  accompanied  by  hemorrhage  from 
wounded  vessels  in  the  mesentery.  These  vessels  should  be  ligated 
with  catgut.  If  large,  and  especially  if  divided  close  to  the  gut,  it  is 
well,  after  ligating  the  bleeding  vessels,  to  resect  the  corresponding 
segment  of  the  gut,  as  such  injuries  are  very  apt  to  be  followed  by 
gangrene  of  that  part  of  gut  which  is  dependent  for  its  supply  upon 
the  injured  vessels. 

The  incision  for  injuries  of  this  character  is  usually  made  in  the 
middle  line,  four  to  five  inches  long,  reaching  from  the  umbilicus 
downward  toward  the  symphysis.  The  incision  may  be  prolonged 
upward  toward  the  ensiform  cartilage,  passing  to  the  left  of  the  um- 
bilicus. The  operator  should  avoid  laying  the  abdomen  open  from 
the  ensiform  cartilage  down  to  the  symphysis  pubis  in  the  eager- 
ness of  his  search  for  wounds  in  the  gut.  If  it  becomes  necessary 
to  increase  the  length  of  the  incision  very  much,  that  portion  of  it 
which  is  not  in  immediate  use  may  be  brought  together  temporarily 
with  a  few  interrupted  silk  sutures  which  pierce  the  whole  thickness 
of  the  abdominal  wall. 

Having  opened  the  abdomen,  one  should  make  a  systematic  ex- 
amination of  the  intestine  from  one  end  to  the  other,  commencing 
at  the  lowest  part  of  the  ileum,  where  it  enters  the  caecum.  This 
part  of  the  gut  should  be  sought  and  drawn  out  upon  the  abdomen, 
and  from  this  point  on  the  small  intestine  and  mesentery  should  be 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  253 

carefully  inspected,  coil  after  coil  being  drawn  out  and  examined 
and  then  re-placed  until  the  upper  end  is  reached. 

As  a  rule,  penetrating  gunshot  and  stab  wounds  of  the  abdomen 
are  accompanied  by  multiple  perforations  of  the  gut  and  mesentery, 
— may  be  as  many  as  fifteen  or  twenty, — and,  when  one  perforation 
in  the  gut  is  located,  usually  a  second  is  found  in  the  same  segment 
at  a  corresponding  point  opposite.  Each  time  a  projectile  passes 
through  the  gut  it  makes  two  wounds — one  of  entrance  and  one  of 
exit. 

Where  we  locate  a  perforation  of  the  gut  we  usually  find  the 
mucous  membrane  protruding  and  tending  to  plug  up  the  opening, 
nature's  effort.  Here  we  pause,  replace  the  mucous  membrane,  wipe 
off  the  margins  of  the  opening  with  alcohol  followed  by  a  weak  bi- 
chloride solution,  and  close  it  with  two  or  three  interrupted  Lembert 
sutures  of  fine  silk;  these  sutures  should  be  placed  about  one-eighth 
inch  apart,  and  care  should  be  taken  to  invert  the  edges  of  the  wound 
and  to  bring  the  serous  surfaces  into  close  apposition. 

In  suturing  these  wounds  the  caliber  of  the  gut  should  not  be 
reduced  more  than  one-third. 

We  then  continue  along  in  the  search  for  further  wounds. 
Wounds  involving  the  mesenteric  border  of  the  gut,  especially  if  the 
adjoining  mesentery  is  torn,  are  unfavorable  for  suture;  in  the  first 
place,  the  serous  coat  on  this  part  of  the  gut  is  imperfect,  has  a 
"dead  space";  and,  in  the  second  place,  if  any  of  the  mesenteric 
vessels  are  divided  close  to  the  gut,  the  corresponding  segment  of 
the  gut  is  apt  to  become  gangrenous;  therefore  it  is  wise,  in  many 
cases,  to  resect  such  a  segment  of  gut  at  once. 

Bleeding  vessels  in  the  mesentery  should  be  clamped  and  tied 
with  plain  catgut. 

After  the  whole  length  of  the  small  intestine  has  been  explored 
one  should  examine  the  whole  length  of  the  large  intestine,  the 
stomach,  and  the  bladder  for  perforations,  and  look  further  for 
hemorrhage,  which  might  indicate  wounds  of  the  liver,  spleen,  kid- 
neys, etc. 

Hemorrhagic  oozing  from  the  solid  viscera  is  usually  readily 
controlled  by  the  Paquelin  cautery  or  by  packing,  or  the  edges  of 
a  gaping  wound  may  be  brought  together  with  several  deep  catgut 
sutures,  although  these  tend  to  tear  through  if  any  tension  exists. 
Any  spurting  vessels  in  the  solid  viscera  should  be  clamped  and  tied 
with  catgut. 


254  ABDOMEN  AND  BACK. 

Having  thus  completed  the  examination  of  the  entire  length  of 
the  alimentary  canal,  etc.,  closed  all  wounds,  and  controlled  the 
hemorrhage,  the  whole  abdominal  cavity  may  be  flushed  out  with 
hot  saline  solution,  using  a  considerable  quantity — best  poured  from 
a  pitcher. 

During  the  search  for  wounds,  etc.,  one  should  replace  the  gut, 
coil  after  coil,  as  fast  as  it  is  examined.  While  the  intestine  is  out- 
side the  abdomen  it  should  be  carefully  protected  with  hot  sterile 
towels,  which  may  be  wet  in  hot  saline  solution.  After  a  time  the 
wet  cloths,  if  not  repeatedly  wet  with  hot  water,  become  cooled;  there- 
fore some  surgeons  prefer  dry  sterile  compresses  for  this  purpose. 

If  it  is  necessary  to  have  a  considerable  portion  of  the  length 
of  the  gut  outside  upon  the  abdomen,  it  should  be  supported  so  that 
it  does  not  drag  upon  the  mesentery;  this  should  be  avoided,  how- 
ever, as  much  as  possible,  as  it  adds  greatly  to  the  shock  and  there 
may  be  some  difficulty  experienced  in  returning  the  distended  coils 
of  gut  into  the  abdomen  again. 

If,  owing  to  the  distension  of  the  guts  with  gas,  it  becomes  dif- 
ficult to  replace  them  within  the  abdomen,  it  may  be  necessary  to 
make  punctures  to  allow  the  gas  to  escape.  In  doing  this  it  is  prob- 
ably better  to  make  a  few  rather  large  openings  with  a  fairly  large 
aspirating  needle  or  a  scalpel  to  allow  gas  to  escape,  closing  them 
afterward  with  a  Lembert  stitch;  this  plan  is  probably  better  than 
numerous  small  punctures  made  with  a  fine  instrument. 

The  abdominal  incision  should  be  carefully  closed,  first  sewing 
the  edges  of  the  parietal  peritoneum  together  with  a  continuous  No. 
2  catgut  suture;  then,  with  a  sufficient  number  of  interrupted  silk- 
worm sutures,  the  edges  of  the  skin  and  aponeurosis  are  brought 
together,  each  stitch  including  all  the  layers  of  the  abdominal  wall 
except  the  parietal  peritoneum. 

Enterectomy. — Eesection  of  a  portion  of  the  gut  (small  intes- 
tine); the  length  of  gut  resected  may  vary  from  several  inches  to 
several  feet.  The  operation  is  performed  for  wounds  which  may 
not  be  safely  closed  by  suture;  for  those  associated  with  division  of 
the  mesenteric  vessels,  especially  if  they  are  divided  close  to  the 
intestine;  for  malignant  growths;  for  gangrene,  strangulation;  for 
fistula,  etc. 

The  incision  is  usually  made  in  the  middle  line,  four  or  five 
inches  long,  reaching  from  the  umbilicus  downward  toward  the  sym- 
physis.    The  portion  of  intestine  to  be  resected  should  be  gently 


OPERATIONS  UPOX  THE  SMALL  IXTESTLXE.  055 

freed  from  adhesions,  if  there  are  any,  and  brought  out  upon  the 
abdomen,  together  with  an  adjoining  portion  of  healthy  gut,  four  to 
six  inches  to  either  side  of  the  part  which  is  to  be  resected;  the  gut 
should  be  supported  upon  dry,  sterile  gauze  compresses,  some  of  which 
are  also  packed  into  the  abdominal  incision  to  protect  the  peritoneal 
cavity. 

In  order  to  prevent  the  escape  of  intestinal  contents  during 
the  operation,  two  gauze  strips  may  be  tied  around  the  gut,  one 
beyond  each  extremity  of  the  segment  which  is  to  be  excised.  An 
assistant  may  compress  the  gut  between  his  fingers  or  temporary 
intestinal  clamps  may  be  applied,  but  the  gauze  strips  are  probably 
more  convenient.  In  order  to  carry  the  gauze  strips  around  the  gut, 
a  thin-nosed  artery  forceps  is  thrust  through  the  mesentery  close 
to  the  gut,  and  with  this  the  end  of  the  gauze  strip  is  seized  and  pulled 
through.  One  strip  is  tied  and  the  contents  of  the  gut  gently  stroked 
along  with  the  fingers  beyond  the  second  strip,  and  then  this  is  tied 
also.     TTe  have  thus  a  fairly  empty  coil  to  operate  upon,  the  strips 


Fig.  106. — Intestine  Compressor. 

being  tied  just  tight  enough  to  prevent  the  re-entrance  of  contents. 
The  strips  should  be  applied  to  the  gut  at  a  sufficient  distance  beyond 
the  portion  which  is  to  be  excised  to  allow  convenient  working  space. 
TTe  then  proceed  to  separate  the  portion  of  gut  that  is  to  be  ex- 
cised from  its  mesenteric  attachment.  This  is  done  by  tying  the 
mesentery  off  in  segments,  each  ligature  including  about  one  inch 
of  the  length  of  the  mesentery;  the  ligatures  should  be  of  thin 
catgut  (So.  1  or  2).  and  each  tied  single  about  one  inch  away  from 
the  mesenteric  edge  of  the  gut.  These  ligatures  may  be  passed  either 
with  a  narrow-bladed  artery  forceps  or  a  blunt  ligature  carrier.  One 
must  be  careful  not  to  tie  off  a  greater  length  of  mesentery  than 
that  which  actually  corresponds  to  the  segment  of  gut  which  is  to 
be  excised,  because  gut  which  has  been  deprived  of  its  mesentery  is 
deprived  of  its  blood-supply  and  is  bound  to  slough.  One  should 
rather  err  in  the  other  direction,  tying  off  a  little  less  mesentery 
than  that  which  corresponds  to  the  length  of  gut  to  be  excised. 
After  the  mesentery  has  been  thus  tied  off  the  segment  of  gut  that 


256 


ABDOMEN  AND  BACK. 


is  to  be  excised  is  cut  away  from  its  mesenteric  attachment,  using  the 
straight  scissors  and  cutting  between  the  ligatures  and  the  gut;  the 
point  of  the  scissors  should  be  introduced  into  the  openings  made 


Fig.  107. — Enterectomy.  A  loop  of  intestine  has  been  drawn  oi't  through 
the  abdominal  incision  and  tied  off  with  tapes.  The  mesentery  corresponding 
to  the  portion  of  gut  that  is  to  be  excised  has  been  tied  off  in  sections.  The 
dotted  lines  indicate  the  lines  of  section  through  the  mesentery  and  gut. 


by  the  ligatures,  and  the  mesentery  cut  from  hole  to  hole,  and  thus 
finally  through  into  the  last  ligature  opening.  We  are  now  ready  to 
sever  the  gut,  and  this  is  done  with  long,  straight  scissors  that  will 
divide  the  gut  in   one   clean  sweep.     The  gut   should   be   divided 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  257 

straight  across  at  right  angles  to  its  long  axis  or,  better,  somewhat 
obliquely,  so-  that  the  segment  of  gut  excised  measures  rather  more 
upon  its  distal  border  than  upon  its  mesenteric  border.  Bleeding 
points  on  the  cut  edges  of  the  intestine  should  be  clamped,  but,  as  a 
rule,  these  do  not  require  ligation,  since  after  a  few  moments'  press- 
ure they  usually  stop,  especially  after  the  ends  of  the  gut  have  been 
united.  Spurting  points,  however,  should  be  clamped  and  tied  with 
fine  catgut.  Contents  that  escape  from  the  ends  of  the  bowel  as  the 
section  is  made  should  be  sponged  away,  and  care  should  be  taken 
that  the  pads  of  gauze  are  so  arranged  as  to  prevent  the  entrance  of 
any  of  this  material  into  the  abdominal  cavity. 

"We  are  now  ready  to  restore  the  continuity  of  the  intestinal 
canal.    This  may  be  accomplished  by: — 

1.  End-to-end  anastomosis,  the  most  desirable. 

(a)  Suture. 

(b)  Invagination  and  suture  (Mounsell). 

(c)  Murphy  button. 

(d)  Laplace  anastomosis  forceps. 

(e)  O'Hara  anastomosis  forceps. 

2.  Side-to-side,  or  lateral,  anastomosis;  applicable  to  both  small 
and  large  intestine. 

(a)  Suture. 

(b)  Murphy  button. 

(c)  McGraw's  rubber  ligature. 

(d)  Laplace  anastomosis  forceps. 

(e)  O'Hara  anastomosis  forceps. 

3.  End  to  side;  this  method  is  used  to  join  the  ileum  to  the 
large  intestine  (see  "Resection  of  Csecum")  and  to  join  the  end  of 
the  duodenum  to  the  stomach  after  pylorectomy  (see  "Pylorectomy, 
Kocher"). 

End-to-End  Anastomosis.  Sutuee. — The  ends  of  the  intestine, 
after  being  cleansed  and  swabbed  off  with  a  bichloride  pad,  are  joined 
together  all  around  with  a  continuous  suture.  This  suture  commences 
at  the  mesenteric  border  of  the  gut  and  unites  the  two  segments  of 
the  gut  end  to  end  all  around.  This  suture  is  continuous,  and  may 
be  of  fine  silk  or  catgut  (No.  2).  It  is  applied  with  a  curved  sur- 
geon's needle,  sewing  from  within,  so  that  the  resulting  suture  line 
presents  into  the  lumen  of  the  gut.  This  suture  includes  all  the 
layers  of  the  wall  of  the  gut,  should  take  a  good,  broad  bite,  and  each 
loop  should  be  drawn  fairly  tight. 


258  ABDOMEN  AND  BACK. 

In  beginning  the  suture,  near  the  mesenteric  border  of  the  gut, 
special  care  is  needed,  in  passing  the  first  stitch,  to  include  the  serous 
coat  in  the  bite  of  the  needle,  as  it  is  in  this  situation  that  the  mesen- 
tery splits  to  invest  the  intestine  and  is  here  not  applied  close  down 
upon  the  muscular  coat  of  the  intestine;  therefore,  unless  special 
pains  are  taken  to  include  the  serous  coat  in  the  stitch,  this  will  be 
a  weak  spot,  slow  to  heal,  and  may  allow  leakage. 

In  uniting  the  two  ends  of  the  gut  in  this  manner  the  last  few 
stitches  must  be  applied  interrupted,  but  they  should  be  tied  so  that 
the  joined  edges  of  the  gut  will  be  inverted  and  look  inward  into  the 
lumen  of  the  gut,  and  the  knots  present  upon  the  inner  aspect  of 


Fig.  108. — End-to-End  Anastomosis.  Gut  joined  end  to  end  by  a  contin- 
uous stitch  introduced  from  within  the  gut  and  penetrating  all  the  layers 
(Woelfler).  Corresponding  to  the  mesenteric  border  of  the  gut  there  may  be 
observed  the  "dead  space"  left  by  the  diverging  layers  of  the  mesentery. 

the  united  intestine.  The  knots  of  the  last  one  or  two  stitches  will, 
of  necessity,  have  to  be  on  the  outside  of  the  gut,  but  this  will  not 
prevent  the  edges  of  the  gut  being  properly  inverted.  As  before 
noted,  especial  care  is  required,  in  applying  this  stitch  to  that  part 
of  the  gut  immediately  adjacent  to  the  mesenteric  attachment,  to 
include  the  serous  layer  of  the  gut  and  thus  do  away  with  the  "dead 
space"  which  normally  exists  in  this  situation  between  the  serous 
and  muscular  coats  of  the  intestine. 

Having  thus  completed  the  junction  of  the  gut  end  to  end,  and 
having  wiped  the  parts  immediately  adjacent  to  the  line  of  suture 
with  a  wet  bichloride  pad,  we  may  proceed  to  apply  a  second  con- 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  259 

tinuous  Lembert  suture  of  fine  black  silk.  This  Lembert  stitch  is 
introduced  with  a  straight  cambric  needle,  and  includes  only  the 
serous  and  muscular  coats;  it  should  completely  bury  the  preceding 
penetrating  stitch,  special  caution  being  used  to  appose  serous  sur- 
face to  serous  surface,  especially  near  the  mesenteric  attachment. 

The  hole  which  is  left  in  the  mesentery,  after  the  segment  of 
gut  has  been  resected  and  the  ends  sutured,  should  be  closed  with 
a  continuous  catgut  stitch,  again  using  special  care  to  bring  the 
edges  of  the  opening  close  together  near  the  surface  of  the  gut. 

The  strips  which  were  placed  around  the  gut  are  now  removed 
and  the  sutured  segment  of  bowel  returned  into  the  abdomen,  and 
placed  in  the  immediate  neighborhood  of  the  abdominal  incision. 

The  incision  in  the  abdomen  is  closed,  either  with  a  single  series 
of  interrupted  silk-worm  gut  sutures  which  include  the  whole  thick- 
ness of  the  abdominal  wall,  and  especially  the  edges  of  the  parietal 
peritoneum,  or,  better,  the  edges  of  the  parietal  peritoneum  may  be 
brought  together,  first  with  a  continuous  catgut  stitch,  and  then, 
in  addition  to  this,  the  other  layers  of  the  abdominal  wall  may  be 
united  with  a  sufficient  number  of  interrupted  silk-worm  gut  sutures. 

Mounseli/s  Method.  —  After  having  excised  the  segment  of 
gut  as  above  described,  the  cut  ends  are  placed  close  together,  edge 
to  edge,  supported  upon  gauze  pads  outside  the  abdomen.  With  a 
moderately  large,  straight  needle  and  fairly  thick  silk  the  edges  of 
the  cut  ends  of  the  gut  are  fixed  to  each  other  at  four  different  points 
of  their  circumference  equidistant  from  one  another.  These  sutures 
are  to  serve  simply  as  tractors.  The  first  is  applied  at  a  point 
corresponding  to  the  mesenteric  attachment,  the  second  at  a  point 
directly  opposite  this,  and  the  other  two  at  points  midway  between 
these.  Each  of  these  sutures  should  include  all  the  coats  of  the  gut, 
special  care  being  taken  to  catch  the  mucous  membrane  and  the 
serous  coats;  the  suture  at  the  mesenteric  border,  particularly, 
should  take  a  good  hold  of  the  serous  coat  to  insure  its  inversion 
at  this  point.  Each  suture  should  be  applied  from  within  the  gut, 
so  that,  when  tied,  the  knot  will  be  upon  the  inner,  mucous  mem- 
brane aspect  of  the  gut.  As  each  of  these  four  tractor  sutures  is 
passed,  it  is  immediately  tied  and  one  end  cut  short,  leaving  the 
other  end  long.  In  tying,  the  suture  should  not  be  tied  right  down 
upon  the  edges  of  the  gut,  but  rather  loosely,  so  that  afterward  they 
may  be  readily  removed. 

In  one  or  the  other  segment  of  the  gut,  a  longitudinal  incision 


260 


ABDOMEN  AND  BACK. 


Fig.  109.—  End-to-End  Anastomosis  (MounseU).  The  ends  of  the  two  seg- 
ments have  been  joined  by  four  tractor  sutures,  the  ends  of  which  are  drawn 
out  of  an  opening  made  in  the  gut. 


Fig  110  —Segment  of  the  Wall  of  the  Gut  Removed  to  Show  the  Invagina- 
tion of  One  Coil  of  Gut  into  the  Other  which  is  Caused  by  Pulling  upon  the 
Tractors. 


Fig.  HI.— The  Two  Coils  of  Gut,  One  Invaginated  within  the  Other,  have 
been  Drawn  through  the  Incision  in  the  Gut  and  their  Edges  United  all 
Around  with  a  Continuous  Penetrating  Suture. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  261 

is  now  made.  This  incision  is  placed  opposite  the  mesenteric  bor- 
der, should  he  about  one  inch  long,  and  commences  about  one  and 
one-half  inches  distant  from  the  cut  edge  of  the  gut.  It  is  best  made 
by  picking  up  the  wall  of  the  gut  with  two  toothed  forceps,  and  be- 
tween these,  with  a  sharp,  straight  scissors,  a  clean-cut  incision  is 
made  through  the  whole  thickness  of  the  wall  of  the  gut.  Through 
this  incision  a  narrow  artery  forceps  is  passed'  into  the  gut  and  the 
tails  of  the  four  tractor  sutures  seized  and  pulled  through,  thus 
drawing  the  ends  of  the  gut  after  them,  with  the  result  that  the  one 
segment  of  gut  is  invaginated  into  the  other,  their  serous  surfaces 
lying  in  contact  with  each  other  and  their  corresponding  edges  in 
apposition  all  around.  The  four  tractor  sutures  are  held  by  assist- 
ants and  put  somewhat  upon  the  stretch,  and  then  the  corresponding 
edges  of  both  segments  of  the  gut  are  ready  to  be  joined  by  suture. 
The  edges  are  sewed  together  with  an  overhand  stitch  with  a  straight 
needle  and  fine  silk.  This  suture,  at  each  puncture,  should  take  a 
good  bite  and  include  a  margin  of  rather  more  than  one-eighth  inch, 
should  be  fairly  close  (intervals  of  about  one-eighth  inch  between 
needle  punctures),  and  should  be  drawn  fairly  tight.  The  stitch 
should  include  all  the  coats  of  the  gut,  special  pains  being  taken  to 
include  the  serous  coat,  particularly  at  the  mesenteric  border  of  the 
gut.     Catgut  may  be  used  for  this  stitch,  but  silk  is  probably  better. 

Having  united  the  edges  of  the  segments  of  the  gut  as  above 
described,  the  temporary  tractor  sutures  are  removed  and  the  gut 
restored  to  its  natural  position  by  reducing  the  invagination;  the 
incision  in  the  gut  is  then  closed  with  a  continuous  Lembert  stitch. 

All  around  the  circular  junction  of  the  segments,  after  swabbing 
with  a  pad  moistened  with  alcohol,  followed  by  one  wet  with  a  weak 
bichloride  solution,  a  continuous  Lembert  stitch  of  fine  silk  is  ap- 
plied; this  'inverts  the  edges  of  the  gut  and  buries  completely  the 
penetrating  through  and  through  suture. 

The  opening  which  is  left  in  the  mesentery,  after  the  segment 
of  gut  has  been  excised,  is  closed  with  a  continuous  catgut  suture, 
special  care  being  taken  to  make  the  union  accurate  close  to  the 
intestine.  The  gut  is  then  returned  to  the  abdominal  cavity,  being 
placed  near  the  abdominal  incision,  and  the  opening  in  the  abdomen 
closed. 

Mukpht  Button. — Having  resected  the  gut  as  above  described, 
a  running  string  is  placed  in  the  edge  of  each  segment  of  the  gut 
which,  when  drawn  tight  and  tied,  puckers  the  end  of  the  gut  and 


262  ABDOMEN  AND  BACK. 

grasps  the  button  about  its  shank,  leaving  the  flange,  or  cup,  of  the 
button  within  the  gut.  This  running  stitch,  or  purse-string,  is  ap- 
plied in  overhand  fashion,  is  of  fine  silk,  and  carried  upon  two  long 
straight  needles.  This  stitch  should  include  all  the  layers  of  the  gut,  ' 
especially  the  serous  and  the  mucous  membrane;  it  should  not  in- 
clude too  wide  a  margin  of  the  gut,  since  the  amount  of  tissue  which 
is  grasped  between  the  flanges,  or  cups,  of  the  button  may  be  too 
bulky  to  allow  exact  coaptation;  a  margin  rather  less  than  one-fourth 
inch  is  sufficient.  For  the  running  stitch  we  require  a  single  strand 
of  fine  silk  with  a  straight  cambric  needle  at  each  end.  The  running 
stitch  is  commenced  by  piercing  the  mesentery  close  to  the  surface 
of  the  gut,  and  then,  carrying  the  same  needle  back  over  the  edge  of 
the  mesentery,  it  is  again  thrust  through,  so  that  we  thus  have  a 
loop  around  the  cut  edge  of  the  mesentery  close  to  the  surface  of 
the  gut.  Now,  with  this  same  needle,  the  running  suture  is  applied 
to  the  corresponding  half  of  the  circumference  of  the  cut  edge  of 
the  gut;  each  puncture  of  the  needle  should  be  made  from  within 
the  lumen  of  the  gut  from  its  mucous  membrane  aspect,  and  the 
punctures  should  be  about  one-third  inch  apart.  When  a  point  is 
reached  directly  opposite  the  mesenteric  border  of  the  gut,  this 
needle  is  discarded;  the  second  needle  is  then  taken  in  hand  and  the 
second  half  of  the  circumference  of  the  gut  treated  in  exactly  the 
same  manner. 

In  this  way  the  whole  circumference  of  the  gut  is  included, 
leaving  the  two  free  tails  of  the  suture,  which  emerge  upon  the 
serous  surface  of  the  gut  opposite  its  mesenteric  attachment,  ready 
for  tying. 

The  object  in  catching  the  edge  of  the  mesentery  in  the  loop 
of  the  purse-string  suture  is  to  insure  the  turning  in  of  a  serous 
surface  at  this  point  and  at  the  same  time  to  do  away  with  the  "dead" 
mesenteric  space;  besides,  it  gives  a  fixed  point  to  the  suture.  Be- 
fore introducing  the  button  the  first  double  loop  of  a  surgeon's  knot 
should  be  taken  with  the  ends  of  the  purse-string. 

One-half  of  the  button,  grasped  with  a  thumb  forceps  by  the 
edge  of  its  tubal  part,  is  now  introduced  into  the  end  of  the  gut, 
turning  the  button  a  little  on  the  side  to  facilitate  its  introduction, 
and  while  it  is  thus  held  the  purse-string  is  tied  around  its  shank, 
leaving  the  flange  within  the  intestine.  The  ends  of  the  purse- 
string  are  cut  short  so  that  they  will  not  protrude  between  the  flanges 
of  the  button  when  this  is  closed.     This  procedure  is  repeated  upon 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


263 


the  other  segment  of  gut.  The  two  halves  of  the  button  are  then  delib- 
erately pressed  home,  and  in  doing  this  one  should  note  that  the  corre- 
sponding mesenteric  attachments  of  either  segment  of  gut  are  opposite 
each  other. 

When  the  two  halves  of  the  button  are  locked  there  should  be 


Fig.  112. — End-to-End  Anastomosis  (Murphy  Button). 
With  the  purse-string  suture  a  loop  is  taken  through 
the  layers  of  the  mesentery,  close  to  the  wall  of  the 
gut,  in  order  to  obliterate  the  "dead  space." 


Fig.  113.— Murphy  But- 
ton, the  Two  Halves 
Separated. 


presented  between  them  a  clean,  smooth  line  with  no  raw  mucous 
membrane  edge  protruding,  and  at  the  mesenteric  attachment  the  ap- 
position of  serous  surfaces  should  also  be  assured.  Should  there  be 
any  protruding  edge  of  mucous  membrane  between  the  flanges  of  the 
button  after  this  has  been  locked,  it  may  be  seized  with  a  thumb 


264  ABDOMEN  AND  BACK. 

forceps  and  trimmed  off  short  with  the  scissors.  Any  doubtful  points 
should  be  made  secure  by  adding  several  Lembert  sutures. 

Although  it  is  probably  not  necessary  in  all  cases  to  use  a  layer 
of  Lembert  sutures  in  addition  to  the  Murphy  button  to  secure  ac- 
curate apposition,  nevertheless  it  is  wise  in  many  cases  to  place  a 
continuous  Lembert  stitch  outside  of  the  button  after  the  halves 
have  been  pressed  home,  especially  as  the  presence  of  the  button 
makes  the  application  of  this  stitch  rather  an  easy  matter. 

After  the  hole  in  the  mesentery  has  been  closed  as  described  in 
the  preceding  operation  the  abdominal  wound  is  sutured. 

The  Murphy  button  causes  a  pressure  atrophy  of  the  edges  of 
the  gut  which  are  caught  between  its  flanges.  When  this  atrophy 
is  complete,  the  button  is  liberated,  taking  the  atrophied  ring  of  tissue 
with  it,  and  thus  an  opening  is  left,  at  the  site  of  the  anastomosis, 
which  corresponds  in  size  to  the  full  diameter  of  the  flanges  of  the 
button. 

With  Laplace  Anastomosis  Fokceps. — The  Laplace  anasto- 
mosis forceps  resembles  two  pair  of  haemostatic  forceps,  the  blades 
of  each  being  bent  to  form  half  a  ring.  When  the  two  forceps  are 
united  side  by  side,  their  blades  together  form  a  complete  ring.  The 
two  parts  of  the  instrument  when  joined  are  held  securely  together 
by  means  of  a  clamp  that  is  applied  at  the  rivet.  When  clamped 
the  two  halves  of  the  forceps  work  in  harmony,  and  may  be  opened 
and  closed  like  a  single  instrument.  The  handles  are  provided  with 
a  ratchet,  like  an  ordinary  hasmostatic  forceps,  so  that  when  the  blades 
are  closed  they  remain  locked.  The  instruments  are  supplied  in  five 
sizes.  The  McLean  anastomosis  forceps  is  a  modification  of  the 
Laplace  instrument,  and  is  more  simple  in  its  construction. 

After  the  diseased  portion  of  the  gut  has  been  resected  the  ends 
of  the  bowel  are  united  to  each  other  fairly  close  with  four  pene- 
trating sutures  of  catgut  placed  equidistant  apart,  taking  care,  at  the 
same  time,  that  the  mesenteric  portions  of  both  segments  are  placed 
opposite  each  other.  The  ring-blades  of  the  anastomosis  forceps  are 
then  introduced,  closed,  between  two  of  the  four  sutures,  and  then 
spread  apart  so  that  one  ring-blade  passes  into  each  end  of  the  gut. 
In  order  to  facilitate  the  turning  in,  inversion,  of  the  edges  of  the 
gut  so  that  they  may  be  grasped  all  around  when  the  blades  of  the 
forceps  are  closed,  a  strand  of  silk  may  be  thrown  around  the  four 
stitches  that  unite  the  edges  of  the  gut  so  as  to  encircle  these 
stitches.     By  tightening  this  thread  the  edges  of  both  segments  are 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  265 


Fig.  114.— Laplace  Anastomosis  Forceps  Separated  into  its  Component  Parts. 


Fig.  115. — Laplace  Anastomosis  Forceps  Joined  Together,  its  Blades  Slightly 
Open.    B,  ring  blades;  C,  clamp;  H,  handle;  S,  shank. 


Fig.  116.— Laplace  Anastomosis  Forceps  Joined  Together,  its  Blades  Closed. 


266  ABDOMEN  AND  BACK. 

turned  inward  toward  the  axis  of  the  intestine,  with  the  result  that 
when  the  ring-blades  of  the  forceps  are  closed  they  grasp  the  mar- 
gins of  each  segment  of  the  gut  all  around,  serous  surface  to  serous 
surface.  The  margin  of  each  segment,  for  its  entire  circumference, 
should  he  grasped  between  the  closed  ring-blades  of  the  forceps. 
The  strand  of  silk  is  then  withdrawn. 

The  two  ends  of  the  gut  are  united  to  each  other,  all  around  the 
circumference  of  the  ring-blades  of  the  forceps,  with  a  continuous, 
non-penetrating  Lembert  suture  of  silk  except  at  the  point  where 
the  shank  of  the  forceps  emerges.  After  this  suture  has  been  ap- 
I^lied  the  clamp  is  removed  from  the  forceps,  which  is  then  sepa- 
rated into  its  two  component  parts;  the  blades  of  each  portion  rep- 
resent but  half  a  ring,  and  these  are  withdrawn  from  within  the 
intestine,  one  at  a  time.  The  small  opening  through  which  the  two 
parts  of  the  forceps  were  removed  is  closed  with  one  or  two  non- 
penetrating Lembert  sutures.  If  desired,  a  second  outside  row  of 
Lembert  sutures  may  be  applied  to  still  further  secure  the  union 
of  the  two  ends  of  gut. 

With  O'Hara  Anastomosis  Forceps.— O'Hara's  anastomosis 
forceps  is  composed  practically  of  two  long,  thin-bladed  haemostatic 
forceps  that  may  be  joined  securely  to  each  other,  side  by  side,  with 
a  clamp.  When  thus  joined  together  both  forceps  work  in  harmony 
as  one  single  instrument.  The  handles  of  the  instrument  are  pro- 
vided with  a  ratchet  arrangement  like  ordinary  artery  forceps,  so 
that  when  the  blades  are  closed  they  remain  locked  until  released. 
The  edges  of  the  blades  are  serrated,  so  that  the  parts  within  their 
grasp  cannot  escape,  and  they  are  also  graduated  with  file-marks,  so 
that  one  may  accurately  estimate  the  length  of  tissue  that  is  grasped 
between  them. 

The  coil  of  gut  that  is  to  be  resected  is  brought  out  through  the 
incision  in  the  abdomen  and  the  corresponding  portion  of  the  mesen- 
tery is  tied  off.  One  O'Hara  forceps  is  then  applied  to  the  gut  below 
the  seat  of  disease  and  locked,  and  the  other  forceps  secures  the 
intestine  above  the  seat  of  disease  and  is  likewise  locked.  Each  for- 
ceps grasps  the  gut  at  right  angles  to  its  long  axis.  The  tip  of  each 
forceps,  as  it  grasps  the  intestine,  should  reach  just  to  the  mesenteric 
border.  The  diseased  segment  of  gut  is  then  excised  with  long, 
straight  scissors  in  the  usual  way,  cutting  fairly  close  to  the  blades 
of  each  O'Hara  forceps.  Before  severing  the  gut  ordinary  compres- 
sion clamps  may  be  applied  to  it — one  immediately  above  and  an- 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  267 


Fig.  117.— O'Hara  Anastomosis  Forceps  Separated  into  its  Component  Parts. 


Fig.  118. — O'Hara  Anastomosis  Forceps  Joined  Together,  its  Blades  Open. 


Fig.   119. — O'Hara  Anastomosis  Forceps  Joined  Together,   its  Blades  Closed. 


26S  ABDOMEN  AND  BACK. 

other  immediately  below  the  diseased  portion;  so  that  when  the  gut 
is  divided  there  will  not  be  any  escape  of  the  contents  of  the  intes- 
tinal canal.  The  mesentery  corresponding  to  the  diseased  segment 
of  gut  may  be  tied  off  before  or  after  the  gut  has  been  severed.  The 
two  O'Hara  forceps  are  now  approximated  and  fixed  securely  together 
side  by  side  with  the  clamp. 

Commencing  near  the  rivet  and  working  toward  the  tip  of  the 
forceps,  the  two  segments  of  gut  are  united  with  a  continuous,  non- 
penetrating Lembert  suture.  This  suture  catches  the  wall  of  each 
segment  of  gut  just  beyond  the  blades  of  the  forceps;  so  that  the 
forceps  are  thus  gradually  buried,  being  invaginated  into  the  lumen  of 
the  gut  as  the  suture  progresses.  When  the  tips  of  the  conjoined  for- 
ceps are  reached,  the  gut  and  forceps  are  turned  over,  so  as  to  gain 
access  to  the  other  aspect  of  the  gut,  and  the  suture  is  continued 
along  this  side  of  the  gut  toward  the  rivet  of  the  forceps  until  the 
point  is  reached  where  the  suture  commenced.  In  working  around 
the  tips  of  the  united  forceps  at  the  mesenteric  border  of  the  gut 
care  is  needed  to  include  the  serous  coat  in  the  suture.  The  clamp 
is  now  removed,  separating  the  two  forceps.  First  one  forceps  is 
unlocked  and  withdrawn,  then  the  second  is  unlocked  and  its  blades 
passed  up  and  down  through  the  line  of  junction  to  show  that  this 
is  patent  and  that  none  of  the  stitches  have  been  carried  across  the 
lumen  of  the  gut  so  as  to  include  the  opposite  wall,  and  then  this  is 
likewise  withdrawn.  The  small  opening  that  is  left  in  the  line  of 
junction  after  the  forceps  have  been  withdrawn  is  closed  with  one 
or  two  interrupted  sutures. 

Side-to-Side,  or  Lateral,  Approximation  (Lateral  Intestinal  Anas- 
tomosis).— This  is  the  formation  of  a  fistulous  opening  between  two 
coils  of  intestine  joined  side  to  side. 

This  operation  is  indicated  when  the  ends  of  gut  that  are  to  be 
united  differ  much  in  caliber, — for  example,  to  unite  the  end  of  the 
ileum  to  the  cascum, — or  where  the  intestinal  tube  is  very  narrow, 
as,  for  example,  in  children. 

Suture. — The  parts  are  brought  well  up  into  the  wound  or,  if 
possible,  outside  upon  the  abdomen,  and  are  surrounded  with  gauze 
pads  to  protect  the  peritoneal  cavity.  Gauze  strips  are  then  tied 
around  the  intestine,  and  after  the  diseased  portion  of  the  gut  has 
been  excised  the  cut  end  of  each  segment  of  the  gut  for  about  one 
inch  of  its  length  is  inverted  and  closed  with  a  double  row  of  Lem- 
bert sutures,  thus  converting  each  end  of  the  gut  into  a  blind  pouch. 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  269 

Care  should  be  taken  to  include  the  invaginated  mesentery  in  the 
suture.  One-  should  commence  the  invagination  of  the  end  of  the  gut 
at  its  mesenteric  edge,  inverting  it  about  one  inch  of  its  length,  and 
then  the  rest  of  the  gut  is  very  conveniently  inverted  and  sutured. 
The  next  step  is  the  union  of  the  two  blind  ends  of  the  gut  to 
each  other,  side  to  side,  so  that  the  intestinal  canal,  through  the  new- 
opening  that  is  to  be  made,  will  be  continued  in  a  direct  line,  and 
not  reversed  in  passing  from  one  segment  to  the  other.     The  ends 


Fig.  120. — Lateral  Anastomosis.  The  end  of  each  coil  of  gut  has  been 
closed  by  suture.  The  two  coils  have  been  placed  side  by  side  and  joined 
by  a  continuous  non-penetrating  suture.  An  opening  has  been  made  in  each 
coil  of  gut. 

of  the  gut  should  be  so  placed  that  they  overlap  each  other  for  a 
distance  of  four  to  five  inches;  their  apposed  surfaces  are  then  united 
to  each  other,  for  a  distance  of  from  three  to  four  inches,  by  a  single 
row  of  continuous  Lembert  sutures  of  fine  silk.  After  this  row  of 
Lembert  sutures,  which  forms  the  posterior  half  of  the  "outside 
serous  ring,"  has  been  applied,  this  needle,  still  carrying  the  fine  silk, 
is  laid  aside  until  required  later  to  complete  this  "outside  serous 
ring."    This  line  of  Lembert  sutures  should  be  one  inch  longer  than 


270 


ABDOMEN  AND  BACK. 


the  proposed  openings  in  the  gut,  and  each  stitch  should  he  rather 
less  than  one-fourth  inch  distant  from  its  neighbor  and  should  be 
drawn  tight. 

Each  segment  of  the  bowel  is  now  opened  with  the  scissors,  the 
incisions  being  placed  about  one-fourth  inch  distant  from  the  line 
of  the  Lembert  suture;  the  openings  in  the  bowel  should  be  large 
so  as  to  allow  for  subsequent  contraction, — three  inches  long  and 
at  least  one  inch  shorter  than  the  line  of  the  Lembert  suture. 

Bleeding  from  the  edges  of  the  incisions  in  the  bowel  is  con- 
trolled with  clamps,  which  may  be  removed  after  a  few  minutes' 
pressure,  as  the  hemorrhage  usually  ceases.     The  edges  of  the  open- 


Fig.  121.— A  Cross  Section  of  the  Apposed  Coils  of  Gut  After  the  Anasto- 
mosis has  been  Completed.  A,  A,  the  outer,  non-penetrating  suture,  the 
"outside  serous"  suture;  B,  B,  the  buried  suture  that  penetrates  all  the 
layers  of  the  wall  of  the  gut,  joining  the  contiguous  edges  of  the  opening 
in  each  segment  all  around.  *,  the  "dead  space"  corresponding  to  the  mesen- 
teric border  of  the  gut  where  the  layers  of  the  mesentery  separate  to  invest 
the  gut. 

ings  in  the  gut  are  wiped  with  alcohol  followed  by  a  weak  bichloride 
solution,  and  then,  with  a  continuous  silk  suture,  which  at  the  same 
time  controls  the  hemorrhage,  the  edges  of  the  opening  in  each  seg- 
ment of  the  bowel  are  united  with  each  other  all  around. 

Having  thus  united  the  edges  of  the  openings  all  around,  we 
again  take  up  the  needle  carrying  the  original  fine  silk  suture  and 
complete  the  anastomosis  by  making  the  anterior  half  of  the  Lem- 
bert suture,  the  "outside  serous  ring." 

The  line  of  Lembert  suture  serves  to  bury  the  suture  by  which 
the  margins  of  the  openings  in  the  gut  are  joined  to  each  other. 

In  making  the  lateral  anastomosis  one  should  not  have  the  blind 
ends  of  the  overlapped  gut  too  long,  and,  further,  the  blind  ends 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  271 

should  be  anchored  to  the  adjoining  portion  of  the  intestine  by  sev- 
eral Lembert  stitches. 

It  may  be  necessary  to  tear  the  mesentery  somewhat  in  order 
to  allow  sufficient  overlapping  of  the  ends  of  the  bowel.  After  the 
anastomosis  has  been  made  the  adjoining  overlapping  layers  of  the 
mesentery  may  be  united  with  a  continuous  catgut  stitch.  The  parts 
should  then  be  returned  to  the  abdomen  and  the  wound  closed  up. 

Murphy  Button.  —  A  lateral  intestinal  anastomosis  may  be 
made  with  the  Murphy  button.  After  the  ends  of  the  gut  have 
been  inverted  and  closed  with  a  suture  as  described  in  the  preceding 
operation,  the  two  ends  are  placed  side  by  side  and  a  purse-string 
suture  placed  in  each  segment;  the  incisions  are  then  made  and  the 
buttons  inserted  in  the  usual  way.  This  is  rather  an  unsatisfactory 
method  of  doing  a  primary  lateral  intestinal  anastomosis,  because 
the  opening  left  by  the  Murphy  button  is  too  small  to  allow  for  the 
subsequent  contraction  that  always  takes  place.  We  may  use  the 
Murphy  button  with  satisfactory  result  in  making  a  lateral  anasto- 
mosis in  connection  with  a  primary  gastro-enterostomy  (see  Fig. 
125;  also  "Cholecysto-duodenostomy"  for  description  of  the  purse- 
string  suture  and  the  method  of  its  introduction). 

McGraw's  Eubber  Suture. — With  the  rubber  suture  a  lateral 
intestinal  anastomosis  may  be  made  in  a  manner  analogous  to  that 
described  for  the  gastro-enterostomy.  The  surfaces  of  the  two  seg- 
ments of  gut  that  are  to  be  joined  are  placed  side  by  side  and  united 
for  a  distance  of  about  two  and  one-half  inches  with  a  continuous 
Lembert  stitch  of  silk  as  described  in  the  previous  operation,  and 
then  the  needle  carrying  this  stitch  is  temporarily  laid  aside.  The 
rubber  suture,  2  to  3  mm.  thick,  is  now  introduced  with  a  straight 
needle,  so  as  to  include  both  segments  of  the  gut  in  its  grasp,  is 
drawn  tight,  and  tied.  A  silk  ligature  is  tied  around  the  knot  in  the 
rubber  suture  so  as  to  secure  the  latter  from  slipping.  About  two 
inches  of  the  wall  of  each  segment  of  the  gut  should  be  included  in 
the  constricting  rubber  suture;  so  that,  when  this  cuts  through,  the 
opening  left  between  the  two  coils  of  gut  will  be  two  inches  in 
length  (see  "Gastro-enterostomy  with  McGraw's  Eubber  Suture"). 

The  needle  carrying  the  silk  Lembert  suture  is  now  again  taken 
up,  and  with  this  the  two  coils  of  gut  are  still  further  united  along 
a  line  just  outside  of  the  rubber  suture.  This  forms  the  second  half 
of  the  "outside  serous  ring"  suture,  and  buries  the  rubber  suture 
beneath  it  out  of  sight. 


272  ABDOMEN  AND  BACK. 

With  Laplace  Forceps.  —  Lateral  anastomosis  with  Laplace 
forceps  is  accomplished  in  a  manner  analogous  to  that  described  for 
gastroenterostomy. 

With  O'Hara  Anastomosis  Forceps. — Lateral  anastomosis 
with  the  O'Hara  forceps  is  done  in  a  manner  similar  to  that  de- 
scribed for  gastroenterostomy. 

Gastroenterostomy. — Gastroenterostomy  is  the  formation  of  a 
fistulous  communication  between  the  stomach  and  the  small  intes- 
tine. 

The  operation  is  indicated  where  the  pyloric  orifice  is  con- 
stricted, either  simple,  following  ulcer,  etc.,  or  malignant.  The 
operation  was  first  performed  by  Woelfler  in  1881.  The  loop  of 
small  intestine  may  be  fixed  to  either  the  anterior  or  the  posterior 
wall  of  the  stomach. 

The  Anterior  Operation  (Woelfler).  —  This  consists  in 
bringing  a  coil  of  the  small  intestine — jejunum — up  in  front  of  the 
great  omentum  and  transverse  colon  and  fixing  it  to  the  anterior 
wall  of  the  stomach. 

The  stomach  should  be  washed  out  while  the  patient  is  anaes- 
thetized, immediately  before  the  operation. 

An  incision  is  made  in  the  middle  line  through  the  linea  alba 
from  a  point  one  inch  below  the  ensiform  cartilage  down  to  the 
umbilicus,  or  even  beyond  this  point  if  necessary.  The  incision  is 
usually  about  four  inches  long  (10  to  15  cm.). 

Through  this  opening  the  stomach  is  sought  and  examined.  A 
portion  of  the  wall  of  the  stomach  which  is  not  involved  in  the  dis- 
ease should  be  selected.  The  stomach  is  partly  covered  by  the  liver, 
the  anterior  thin  edge  of  the  left  lobe  of  the  liver  being  a  good 
guide  to  the  stomach.  Lying  below  and  close  to  the  greater  curva- 
ture of  the  stomach  is  the  transverse  colon,  and  from  this  the  great 
omentum,  apron-like,  is  suspended,  hanging  down  free  in  the  abdom- 
inal cavity  in  front  of  the  small  intestine. 

After  the  stomach  has  been  recognized  the  transverse  colon,  and 
with  it  the  great  omentum,  are  drawn  upward  out  of  the  wound, 
and  search  is  then  made  for  the  commencement  of  the  jejunum. 
This  part  of  the  gut  lies  in  the  back  of  the  abdominal  cavity,  to  the 
left  of  the  vertebral  column,  upon  a  level  with  the  second  lumbar 
vertebra,  its  mesentery  being  very  short  and  serving  to  anchor  it  in 
this  position.  To  secure  this  coil  of  gut  the  hand  is  introduced  into 
the  abdomen  and  carried  backward,  along  the  under  surface  of  the 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


273 


transverse  mesocolon,  as  far  as  the  posterior  abdominal  wall;  just  be- 
low the  attachment  of  the  transverse  mesocolon  to  the  vertebral 
column,  at  the  place  indicated  upon  the  left  of  the  column,  this  coil 
of  gut  is  found. 

This  part  of  the  small  intestine  is  readily  identified  by  the  fact 
that  it  is  fixed  within,  as  is  shown  when  an  effort  is  made  to  draw  it 
out  of  the  abdomen;    any  other  part  of  the  small  intestine  may  be 


Fig.  122. — Gastroenterostomy.  The  jejunum  has  been  fixed  to  the  stom- 
ach and  an  opening  made  between  them.  Arrows  (1,  1)  show  the  proper 
course  of  the  stomach  contents  into  the  long  arm  of  the  gut.  Arrows  (2,  2) 
show  the  course  of  stomach  contents  into  the  short  arm  of  the  gut,  through 
which  they  may  again  enter  the  stomach,  "vicious  circle." 


drawn  through  the  fingers  in  either  direction,  and  may  be  readily 
drawn  out  upon  the  abdomen. 

We  select  a  loop  of  gut  for  attachment  to  the  stomach  from 
eighteen  to  twenty  inches  distant  from  this  fixed  part  of  the  jeju- 
num. A  loop  of  gut  about  eight  inches  long  is  drawn  out  upon 
the  abdominal  wall  and  surrounded  and  constricted  by  two  thin 
strips  of  sterile  gauze.  A  sharp-nosed  artery  forceps  is  thrust  through 
the  mesentery  near  its  attachment  to  the  intestine,  and  with  this 
the  end  of  each  gauze  strip  is  seized  and  drawn  through.     The  one 

18 


274  ABDOMEN  AND  BACK. 

strip  is  tied  and  the  segment  of  gut  emptied  of  its  contents,  to  a 
point  beyond  the  second  piece  of  gauze,  by  gently  stripping  it  be- 
tween the  fingers,  and  then  the  second  gauze  strip  is  tied.  The 
gauze  strips  should  be  tied  sufficiently  tight  to  prevent  the  re- 
entrance  of  the  intestinal  contents  into  this  segment  of  the  gut. 
The  transverse  colon  and  great  omentum  are  now  pushed  back  into 
the  abdomen  again,  and  the  anterior  surface  of  the  stomach  seized 
and  drawn  out  of  the  abdomen.  Dry,  sterile,  gauze  pads  are  placed 
about  the  stomach  and  intestine  and  tucked  partly  into  the  in- 
cision for  the  purpose  of  retaining  the  parts  outside  of  the  ab- 
domen and  to  prevent  the  entrance  of  escaping  intestinal  contents 
into  the  peritoneal  cavity.  The  rest  of  the  operation  is  done  extra- 
peritoneally. 

The  coil  of  intestine  and  the  stomach  are  steadied,  side  by  side, 
and  united  by  a  continuous  Lembert  suture  of  fine  black  silk,  using 
a  straight  cambric  needle.  This  suture  line,  which  includes  the 
serous  and  muscular  coats,  forms  the  posterior  half  of  the  "outside 
serous  ring."  It  should  not  penetrate  into  the  cavity  of  the  stomach 
or  intestine.  The  suture  should  be  applied  in  a  straight  line,  about 
two  and  one-half  to  three  inches  long,  each  puncture  of  the  needle 
being  about  one-eighth  inch  distant  from  its  neighbor,  and  should 
take  a  good,  broad  bite.  Each  stitch  should  be  drawn  fairly  tight.  It 
is  probably  more  convenient  for  the  operator,  in  applying  this  suture, 
to  commence  at  the  far  end  and  sew  toward  himself,  steadying  the 
parts  with  the  thumb  and  index  finger  of  left  hand.  The  tail  of  the 
suture  should  be  left  long,  and  may  be  held  by  the  assistant  as  a 
tractor.  After  this  line  of  suture  has  been  completed,  the  needle, 
carrying  this  thread,  is  laid  aside  until  needed  later  to  complete  the 
operation  by  making  the  anterior  half  of  the  "outside  serous  ring" 
suture. 

The  openings  in  the  intestine  and  stomach  are  next  made. 
These  incisions  should  be  one  and  one-half  to  two  inches  long.  They 
should  be  shorter  than  the  line  of  the  Lembert  suture,  and  should 
be  placed  about  one-fourth  inch  distant  from  this.  The  intestine 
should  be  incised  first,  the  incision  being  placed  opposite  its  mesen- 
teric border  and  any  escaping  contents  carefully  swabbed  away. 
These  incisions  should  be  straight  and  clean  cut.  The  wall  of  the 
gut  is  caught  up  with  two  toothed  forceps,  and  a  small  opening  made 
between  these  with  a  straight,  sharp  scissors,  and  then  this  opening 
is  sufficiently  enlarged.     The  stomach  is  then  treated  in  a  similar 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  275 

manner.  Hemorrhage  from  the  edges  of  these  incisions  stops  after 
they  have  been  sutured;  any  spurting  points  may  be  clamped  and 
tied  with  fine  silk  or  catgut. 

The  adjoining  edges  of  the  incisions  in  the  intestine  and  stom- 
ach are  now  sewed  to  each  other  with  catgut  or  silk  in  a  medium- 
sized,  straight  needle,  each  stitch  taking  a  good  bite  and  passing 
through  all  the  coats,  including  the  mucous  membrane,  and  drawn 
fairly  tight;  the  needle  punctures  should  be  rather  less  than  one- 
fourth  inch  apart.  This  suture  is  continued  uninterrupted  all 
around,  uniting  the  corresponding  edges  of  the  incisions  in  the 
stomach  and  intestine  to  each  other  until  these  openings  are  entirely 
closed  in  and  the  anastomosis  made.  Before  beginning  this  stitch 
the  margins  of  the  openings  should  be  wiped  off  with  alcohol  fol- 
lowed by  a  weak  bichloride  solution  on  a  swab. 

We  now  again  take  up  the  needle  with  which  the  posterior  half 
of  the  Lembert  suture — "outside  serous  ring" — was  made,  and  com- 
plete the  operation  by  making  the  anterior  half  of  the  "outside 
serous  ring"  suture. 

Thus  we  have  the  openings  in  the  intestine  and  stomach,  one 
and  one-half  to  two  inches  long,  united,  edge  to  edge,  by  a  con- 
tinuous stitch  which  passes  through  the  entire  thickness  of  the  mar- 
gins of  the  contiguous  openings,  and  this  surrounded,  reinforced, 
by  a  continuous  Lembert  suture  which  passes  through  the  serous 
and  muscular  coats  only  and  which  serves  the  purpose  of  burying  the 
penetrating  mucous  stitch.  Should  there  be  any  doubtful  points 
where  the  mucous  penetrating  stitch  is  not  certainly  buried,  one  or 
more  supplementary  interrupted  Lembert  stitches  may  be  taken  to 
remedy  this. 

The  coil  of  intestine  should  be  joined  to  the  stomach  near  its 
greater  curvature  and  about  three  inches  from  its  pyloric  opening. 
The  incision  in  the  intestine  should  be  made  opposite  its  mesenteric 
attachment.  The  intestine  should  be  joined  to  the  stomach  in  such 
a  way  that  the  current  of  food  in  the  stomach  and  in  the  loop  of 
intestine  will  be  in  the  same  direction — the  distal  limb  of  the  loop 
of  gut  toward  the  right  or  pyloric  end  of  the  stomach;  this  is  accom- 
plished by  taking  care  not  to  twist  the  loop  of  intestine  upon  itself 
when  drawing  it  up  into  apposition  with  the  stomach. 

The  transverse  colon  and  great  omentum  rolled  upon  itself 
lie  together  behind  the  junction  formed  between  the  jejunum  and 
the  stomach. 


276  ABDOMEN  AND  BACK. 

The  tapes  are  now  removed  from  the  intestine  and  the  parts 
replaced  within  the  abdomen. 

The  opening  in  the  abdomen  is  closed  with  several  silk-worm 
gut  sutures,  which  pass  through  the  whole  thickness  of  the  abdominal 
wall,  care  being  taken  to  include  the  edges  of  the  parietal  perito- 
neum. These  stitches  should  be  about  one-half  inch  apart.  It  is 
probably  better  to  suture  the  edges  of  the  peritoneum  first  with  a 
continuous  catgut  stitch  and  after  this  the  silk-worm  stitches  are 
applied  so  as  to  include  the  other  layers  of  the  abdominal  wall. 

Posteeioe  Operation  (von  Hacker). — The  jejunum  is  sutured 
to  the  posterior  wall  of  the  stomach,  which  is  exposed  through  an 
opening  torn  in  the  transverse  mesocolon. 

This  operation  is  preferred  by  many  surgeons  to  the  anterior. 
The  position  of  the  parts  is  more  natural  and  the  transverse  colon  is 
not  displaced,  and  cannot  drag  upon  the  coil  of  jejunum  that  is  fixed 
to  the  stomach. 

The  technique  of  this  operation  is  no  more  difficult  than  that 
of  the  anterior;  so  that  the  choice  between  the  anterior  and  poste- 
rior operation  will  probably  depend,  in  most  cases,  upon  the  location 
of  the  disease. 

An  incision  is  made  in  the  middle  line  through  the  linea  alba, 
as  in  the  preceding  operation.  The  stomach  is  recognized  and  ex- 
amined. The  transverse  colon  and  greater  omentum  are  then  re- 
flected upward  and  the  stomach  drawn  out  of  the  incision  in  the 
abdomen.  An  opening  at  right  angles  to  the  long  axis  of  the  trans- 
verse colon  is  now  cut,  or,  better,  torn,  in  the  transverse  mesocolon, 
penetrating  from  its  inferior  aspect,  in  order  to  expose  a  sufficient 
area  of  the  posterior  wall  of  the  stomach. 

The  posterior  wall  of  the  stomach  is  then  drawn  partly  through 
the  opening  torn  in  the  transverse  mesocolon,  the  edges  of  the  open- 
ing in  the  mesocolon  being  fixed  at  once  to  the  posterior  wall  of  the 
stomach  by  several  fine  silk  sutures  (which  do  not,  of  course,  pierce 
the  entire  thickness  of  the  stomach  wall).  The  exposed  area  of  the 
stomach  is  then  brought  up  into  the  incision  in  the  abdomen  and  out 
upon  the  abdominal  wall,  where  it  is  retained  by  an  assistant. 

As  in  the  preceding  operation,  the  commencement  of  the  jeju- 
num is  sought  for  and  found  in  the  back  of  the  abdomen  to  the  left 
of  the  body  of  the  second  lumbar  vertebra,  just  below  the  vertebral 
attachment  of  the  transverse  mesocolon.  A  coil  of  intestine  about 
twenty  inches  farther  along  is  selected,  and  this  is  also  brought  out 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


277 


Pig.  123.— Posterior  Gastroenterostomy.  Great  omentum  (GO)  and  trans- 
verse colon  (TC)  have  been  drawn  out  of  the  incision  and  turned  upward. 
An  opening  has  been  made  in  the  transverse  mesocolon  in  order  to  expose  a 
portion  of  the  posterior  wall  of  the  stomach.  A  loop  of  jejunum  has  been 
fixed  to  the  wall  of  the  stomach  with  a  continuous,  non-penetrating  stitch 
and  openings  made  in  the  stomach  and  the  attached  coil  of  gut.  The  loop 
of  gut  has  been  temporarily  tied  off  with  tapes. 


278  ABDOMEN  AND  BACK. 

of  the  abdominal  wound  and  placed  alongside  of  that  portion  of  the 
posterior  wall  of  the  stomach  which  presents  through  the  opening 
in  the  transverse  mesocolon.  Pads  of  gauze  are  then  tucked  about 
the  viscera  and  partly  into  the  abdominal  incision  to  steady  the 
parts  and  to  prevent  the  entrance  of  infectious  material  into  the 
peritoneal  cavity  and  the  gastro-enterostomy  is  performed  as  in  the 
preceding  operation.    The  intestine  is  fixed  to  the  posterior  wall  of 


Fig.  124.— Gastro-enterostomy  (Jaboulay-Braun).  Compare  with  Fig.  122. 
Lateral  anastomosis  has  been  made  between  the  arms  of  the  attached  loop  of 
gut;  so  that  if  the  stomach  contents  do  enter  the  short  arm  of  the  gut  (2,  2) 
they  may  still  escape  into  the  proper  long  arm.  This  measure  prevents  the 
occurrence  of  the  "vicious  circle." 

the  stomach,  near  the  greater  curvature,  and  from  three  to  three  and 
one-half  inches  away  from  the  pylorus.  The  coil  should  be  fixed  so 
that  the  current  of  food  through  the  stomach  and  the  intestine  are 
in  the  same  direction. 

Jabotjlay  and  Braun  Modification. — In  some  cases,  after  the 
anterior  or  posterior  gastro-enterostomy  as  described  above  has  been 
performed,  there  occurs  an  accumulation  of  food,  bile,   and  pan- 


OPERATIONS  UPON  THE  SMALL  INTESTINE. 


279 


creatic  juice  in  the  short  (proximal)  limb  of  the  loop  of  the  intestine 
that  is  fixed  to  the  stomach,  with  a  consequent  regurgitation  into  the 
stomach,  and  this  is  characterized  by  exhausting  and  fatal  vomiting. 
This  regurgitation  and  vomiting  are  due  to  a  spur  formation  in  the 
attached  coil  of  gut  which  directs  the  stomach  contents  into  the  short 
or  proximal  arm  of  the  gut.  In  order  to  avoid  the  occurrence  of  this 
vomiting — "vicious  circle" — a  lateral  communication  between  the 
two  limbs  of  the  coil  of  intestine  which  has  been  attached  to  the 
stomach  may  be  made,  and  this  may  be  done  either  at  the  same  time 
that  the  gastro-enterostomy  is  performed,  or,  since  this  regurgita- 
tion, etc.,  do  not  occur  in  all  cases,  it  may  be  done  later  as  a  sec- 
ondary operation,  in  this  latter  case  waiting  for  the  appearance  of 


Fig.  125. — Lateral  Anastomosis  (Murphy  Button).  Running,  or  purse- 
string,  sutures  applied  and  incisions  made  in  two  coils  of  gut  preparatory  to 
the  introduction  of  the  Murphy  button. 


symptoms  indicating  the  necessity  of  the  additional  operation  before 
submitting  the  patient  to  the  additional  risk.  It  is  probably  wise,  in 
most  cases,  to  do  this  entero-anastomosis  at  the  same  time  as  the 
primary  gastro-enterostomy,  as  it  occupies  but  a  few  minutes'  addi- 
tional time.  This  secondary  entero-anastomosis  may  be  made  with 
suture,  Murphy  button,  or  McGraw's  rubber  suture  or  with  the 
Laplace  or  O'Hara  forceps,  etc.  The  communication  between  the 
two  limbs  of  the  loop  of  gut  should  be  made  at  their  most  dependent 
part, — at  least  five  inches  distant  from  their  point  of  attachment  to 
the  stomach. 

For  description  of  the  running,  purse-string  stitch  and  the 
method  of  its  introduction  in  connection  with  the  Murphy  button 
see  "Cholecysto-duodenostomy." 


280  ABDOMEN  AND  BACK. 

Gastko-extekostomy  with  Muepht  Button. — This  is  simple, 
and  much  time  can  he  saved  by  the  use  of  this  device. 

The  use  of  the  Murphy  button  is  no  doubt  indicated  in  many 
eases,  especially  where  a  malignant  condition  exists  and  the  time 
permitted  for  the  performance  of  the  operation  is  short.  The 
medium-size  button  may  be  used  for  the  gastroenterostomy,  and  a 
smaller  one  for  the  entero-anastomosis,  if  this  latter  operation  is 
performed  in  addition. 

If  a  posterior  gastro-enterostomy  is  done,  the  button,  when 
liberated,  is  less  likely  to  fall  into  the  stomach  than  when  the  ante- 
rior gastro-enterostomy  is  done.  According  to  the  suggestion  of 
Weir,  the  margin  of  that  half  of  the  button  which  presents  into  the 
intestine  may  be  provided  with  projecting  flanges,  which  should 
hinder  the  button  from  falling  into  the  stomach. 

The  stomach  and  intestine  are  brought  out  upon  the  abdomen 
as  in  the  operations  above  described.  A  running  stitch  is  introduced 
into  the  wall  of  the  intestine  and  the  wall  of  the  stomach,  penetrat- 
ing through  the  entire  thickness  of  the  wall  of  each.  The  space  in- 
cluded between  the  two  limbs  of  this  running,  or  purse-string,  suture 
should  be  about  one-half  inch  (for  description  of  the  running,  purse- 
string  suture  and  the  method  of  its  introduction  see  "Cholecysto- 
duodenostomy";  as  applied  in  lateral  anastomosis,  between  two  coils 
of  gut,  see  Fig.  125).  This  purse-string  suture  is  applied  first  to 
the  jejunum,  and  then  between  the  two  limbs  of  the  suture  line  an 
incision  is  made  into  the  gut;  this  should  be  barely  large  enough 
to  permit  the  introduction  of  the  half  button.  The  half  button 
which  is  provided  with  the  spring  is  seized  with  a  thumb  forceps  and 
introduced  sidewise  through  the  incision  into  the  gut,  and,  while  it 
is  thus  steadied,  the  running  string  is  drawn  tight  about  its  shank, 
tied,  and  the  ends  cut  short. 

In  a  similar  manner,  after  the  purse-string  has  been  applied  to 
the  wall  of  the  stomach,  this  is  incised,  and  the  other  half  of  the 
button  is  introduced  into  this  incision  and  the  string  tied  about  its 
neck.  The  parts  adjacent  to  the  openings  are  then  sponged  off  with 
a  wet  bichloride  pad  and  the  two  halves  of  the  button  deliberately 
pressed  home.  They  should  be  applied  sufficiently  tight  to  cause  a 
gradual  pressure  necrosis  of  those  parts  of  the  walls  of  the  viscera 
that  are  included  within  their  grasp.  No  raw  edge  of  mucous  mem- 
brane should  protrude  between  the  two  halves  of  the  button.  If 
any  raw  edge  of  mucous  membrane  should  present  itself  between 


OPERATIONS  UPON  THE  SlIALL  INTESTINE.  281 

the  flanges  of  the  button,  it  should  be  seized  with  the  thumb  forceps 
and  trimmed  close  with  sharp  scissors,  and  then  be  still  farther 
buried  with  seyeral  additional  Lembert  stitches.  Murphy  claims  that 
the  additional  outside  Lembert  stitch  is,  as  a  rule,  unnecessary; 
nevertheless,  it  is  well  to  use  it  if  time  permits,  and  especially  if 
there  are  any  doubtful  points.  The  button  being  within  the  gut 
makes  the  application  of  the  Lembert  stitch  easy.  Spurting  vessels 
in  the  edges  of  the  openings  in  the  intestine  and  stomach  may  be 
clamped  and  tied  with  fine  catgut  or  fine  silk. 

Carle  applies  the  Murphy  button  without  using  the  purse-string. 
A  simple  clean-cut  incision  is  made  in  the  jejunum  and  in  the  stom- 
ach barely  large  enough  to  admit  the  button.  After  the  button  has 
been  introduced  the  incision  is  diminished  by  a  single  Lembert  stitch 
at  each  end  of  the  incision;  and  the  two  halves  of  the  button  then 
pressed  home.  It  is  said  to  be  perfectly  safe  and  to  give  more  per- 
fect apposition  than  with  the  purse-string  and  saves  much  time. 
After  the  button  has  been  introduced  and  locked  several  outside 
Lembert  sutures  may  be  introduced,  especially  if  there  are  any 
doubtful  points  and  if  time  permits. 

Gastro-enterostomy  with  McG raw's  Eubber  Suture. — The 
gut  is  brought  into  apposition  with  the  anterior  or  posterior  surface 
of  the  stomach,  as  described  in  the  preceding  operations,  and  these 
two  portions  of  the  alimentary  canal  are  joined  to  each  other  with 
a  continuous  silk  Lembert  stitch  for  a  distance  of  about  two  and 
one-half  inches.  The  needle  carrying  this  suture  is  then  temporarily 
laid  aside. 

The  stomach  is  then  united  to  the  intestine  with  a  single  suture 
of  solid  rubber,  smooth  and  round  and  from  2  to  5  mm.  in  thickness. 
This  suture  is  carried  in  the  eye  of  a  long  straight  needle;  a  large 
worsted  needle  or  Hagedorn  needle  answers  well  for  this  purpose. 
It  will  be  necessary  to  shave  the  end  of  the  rubber  suture  so  that 
it  may  enter  the  eye  of  the  needle.  The  point  of  the  needle  is  passed 
into  the  stomach  and  then  out  again,  so  that  about  two  inches  of  the 
wall  of  the  stomach,  corresponding  to  its  long  diameter,  is  included 
between  the  two  punctures,  and  then,  with  the  same  needle  and 
suture,  and  in  a  similar  manner,  the  intestine  is  secured,  entering 
and  emerging  at  points  opposite  the  puncture  holes  in  the  stomach. 

The  rubber  suture  is  then  drawn  as  tight  as  possible,  thus  con- 
stricting the  parts  included  in  its  grasp,  and  tied.  In  order  to  secure 
the  knot  in  the  rubber  suture  a  strand  of  stout  silk  may  be  placed 


282 


ABDOMEN  AND  BACK. 


underneath  the  rubber  at  the  place  where  the  knot  is  to  be,  and  after 
one  loop  of  the  knot  has  been  taken  in  the  rubber  suture  the  silk 
ligature  is  tied  over  it  and  then  the  second,  final  loop  of  the  knot  is 
taken  in  the  rubber  suture. 


Fig.  126.— Gastro-enterostomy  (McOraw).  A  loop  of  intestine  has  been 
fixed  to  the  wall  of  the  stomach  with  a  continuous,  non-penetrating  stitch 
{A,  A).  Rubber  ligature  (B,  B,  B),  which  has  been  passed  through  the  stom- 
ach and  intestine,  ready  for  tying. 

In  passing  the  rubber  suture  one  should  make  certain  that  the 
needle  pierces  the  entire  thickness  of  tbe  wall  of  the  organ  and  that 
it  does  not  pick  up  the  mucous  membrane  on  its  way;  in  each  viscus 


OPERATIONS  UPON  THE  SMALL  INTESTINE.  283 

there  should  he  two  punctures  only, — one  as  the  needle  passes  in  and 
one  as  the  needle  passes  out. 

In  drawing  the  ruhher  suture  after  the  needle,  through  the  wall 
of  the  stomach  and  intestine,  it  may  he  stretched  so  that  it  becomes 
thinner,  and  may  thus  the  more  readily  follow  the  needle  through 
the  punctures.  When  the  suture  is  relaxed  it  becomes  increased  in 
diameter  so  that  it  more  than  fills  the  puncture  holes  and  thus  pre- 
vents leakage. 

Finally,  to  complete  the  operation,  the  needle,  carrying  the  silk 
thread  with  which  the  'first  half  of  the  Lemhert  "outside  serous  ring" 
suture  was  applied,  is  again  taken  in  hand  and  with  it  the  wall  of 
the  stomach  and  intestine  are  joined  with  a  continuous  stitch,  which 
is  applied  along  a  line  just  outside  the  location  of  the  rubber  liga- 
ture, and  which  buries  this  latter  and  completes  the  "outside  serous 
ring"  suture. 

By  this  operation  corresponding  portions  of  the  opposed  stom- 
ach and  intestine  are  included  in  the  grasp  of  a  single,  tight,  elastic 
rubber  suture,  which  gradually  cuts  its  way  through  the  walls  of  the 
opposed  viscera;  so  that  after  the  lapse  of  two  or  three  days  the 
gastro-enterostomy  is  established  and  the  liberated  rubber  suture  is 
passed  unobserved  through  the  bowel.  This  method  may  be  em- 
ployed in  making  a  lateral  anastomosis  between  two  coils  of  small 
intestine  or  between  the  small  and  large  intestine. 

G-astbo-enteeostomy  with  Laplace  Fokceps.  —  After  the 
stomach  and  intestine  have  been  brought  up  into  the  abdominal  in- 
cision an  opening  is  made  in  each  viscus,  which  opening  should  be 
rather  smaller  than  the  ring  of  the  forceps  that  is  to  be  used. 

The  blades  of  the  forceps,  joined  together  and  secured  with  the 
clamp,  are  introduced,  one  into  each  organ,  and  then  closed,  with 
the  result  that  the  margins  of  each  opening  are  securely  grasped  be- 
tween them,  serous  surface  being  apposed  to  serous  surface.  Care 
must  be  exercised  to  include  the  entire  margin  of  each  opening  in 
the  grasp  of  the  closed  blades,  and  this  is  facilitated  by  using  an  in- 
strument whose  ring  is  larger  in  circumference  than  the  correspond- 
ing openings  in  the  stomach  and  intestine.  The  wall  of  the  stomach 
and  the  wall  of  the  intestine  are  then  united  all  around  the  circum- 
ference of  the  ring-blades  of  the  forceps,  except  for  the  small  space 
through  which  the  shanks  of  the  forceps  emerge.  This  union  should 
be  made  with  a  continuous,  non-penetrating  Lembert  suture  of  fine 
silk.     The  rinsj-blades  of  the  forceps  which  are  within  the  stomach 


284  ABDOMEN  AND  BACK. 

and  intestine  retain  the  parts  in  accurate  apposition,  and  make  the 
application  of  the  suture  a  matter  of  comparative  ease. 

After  the  suture  has  been  applied  the  clamp  is  removed  from  the 
forceps,  which  is  thus  separated  into  its  two  component  parts,  the 
blades  of  each  of  which  form  but  half  a  ring;  these  are  then  with- 
drawn from  the  stomach  and  intestine,  first  one  and  then  the  other. 
Finally  the  small  opening  through  which  the  separated  forceps  were 
withdrawn  is  closed  with  one  or  two  interrupted  non-penetrating  su- 
tures. A  second  row  of  outside  non-penetrating  Lembert  sutures 
may  be  applied  all  around  the  first  row  of  sutures  if  desired,  in  order 
to  make  the  union  of  the  intestine  to  the  stomach  still  more  secure. 

Gastroenterostomy  with  O'Hara  Foeceps.  —  After  the 
stomach  and  intestine  have  been  drawn  out  through  the  abdominal 
incision  the  wall  of  each  is  picked  up  with  a  mouse-tooth  forceps 
and  securely  grasped  between  the  blades  of  one  of  the  forceps,  along 
a  line  corresponding  to  the  long  axis  of  each  organ,  in  the  same 
manner  as  one  would  grasp  the  prepuce  with  a  circumcision  clamp. 
The  length  of  the  wall  of  the  organ  thus  secured  between  the  blades 
of  the  forceps  will  vary  according  to  the  size  of  the  intended  open- 
ing. The  blades  of  the  forceps  are  graduated  so  that  there  should 
be  no  difficulty  in  securing  the  same  amount  of  each  organ,  and  this 
is  desirable.  As  the  wall  of  the  stomach  or  intestine  is  grasped  the 
tip  of  the  blade  should  reach  exactly  to  the  edge  of  the  process  thus 
secured.  That  part  of  the  wall  of  the  stomach  and  intestine  which 
protrudes  beyond  the  blades  of  the  forceps  is  cut  away  with  the  knife 
or  scissors  fairly  close  to  the  blades.  The  two  forceps  are  then  united 
together  and  securely  locked  with  the  clamp,  and  we  are  ready  for 
the  next  step  of  the  operation,  the  suturing  of  the  wall  of  the  in- 
testine to  the  wall  of  the  stomach.  This  is  done  with  a  continuous, 
non-penetrating  Lembert  suture  of  silk.  Commencing  near  the  rivet, 
this  suture  is  carried  along  the  blades  of  the  forceps  toward  the  tip 
and  then  around  the  tip  of  the  forceps  and  back  again  upon  the  other 
side  to  a  point  near  the  rivet  where  the  suture  was  commenced.  As 
this  suture  progresses  it  serves  to  bury  the  blades  of  the  forceps 
beneath  it. 

The  junction  of  the  stomach  and  intestine  is  thus  complete 
except  for  the  small  space  through  which  the  forceps  emerge.  In 
applying  the  second  half  of  the  suture  it  will  be  necessary  to  turn 
the  forceps  over  and  with  them  the  stomach  and  intestine  in  order 
to  make  the  parts  upon  this  under  side  accessible.     The  clamp  is  now 


SUEGICAL  ANATOMY  OF  THE  LARGE  INTESTINE,  ETC.        285 

removed  from  the  forceps,  which  is  thus  separated  into  its  two  com- 
ponent parts.'  One  forceps  is  unlocked  and  withdrawn.  The  second 
forceps  is  unlocked,  and,  after  being  passed  in  and  out  through  the 
opening  between  the  stomach  and  the  intestine  to  make  certain  that 
this  is  patent  and  that  none  of  the  stitches  have  been  inadvertently 
carried  across  to  the  opposite  margin  of  the  orifice,  this  is  likewise 
withdrawn.  The  small  opening  that  still  remains  and  through  which 
the  forceps  were  withdrawn  is  now  closed  with  one  or  two  non-pene- 
trating Lembert  sutures.  If  desired,  an  additional  row  of  Lembert 
sutures  may  be  placed  outside  the  first  row  in  order  to  strengthen 
the  union. 

THE  LARGE  INTESTINE  AND  VERMIFORM  APPENDIX. 

The  Surgical  Anatomy  of  the  Large  Intestine,  etc. — The  large 
intestine  may  be  distinguished  from  the  small  intestine  by  its  large 
caliber  and  by  its  sacculation;  attached  along  its  whole  length  is  the 
great  omentum  or  the  analogues  of  this  structure,  the  appendices 
epiploicae.  The  large  intestine  is  also  marked  by  three  longitudinal 
bands,  which  traverse  its  entire  length.  These  longitudinal  bands 
are  made  up  of  an  aggregation  of  the  longitudinal  muscular  fibers; 
one  of  them  is  found  along  the  mesenteric  border  of  the  gut,  another 
corresponds  to  the  attachment  of  the  great  omentum  and  the  little 
fatty  processes, — the  appendices  epiploicae, — and  the  third  is  located 
between  these  two. 

The  large  intestine  may  be  divided  into  three  parts:  the  caecum, 
colon  (ascending,  transverse,  descending,  and  sigmoid  flexure),  and 
the  rectum. 

The  C^cum  is  the  dilated,  pouched  commencement  of  the  large 
intestine.  It  is  found  in  the  right  iliac  fossa,  near  the  brim  of  the 
pelvis,  resting  upon  the  psoas  or  iliacus  muscle. 

It  is  provided  with  a  complete  peritoneal  investment,  is  mov- 
able, and  has  a  mesentery  which  is  short  and  serves  to  anchor  it  to 
the  posterior  abdominal  wall.  The  mesentery  is  sufficiently  long, 
however,  to  allow  this  part  of  the  intestinal  canal  to  be  drawn  out 
upon  the  abdominal  wall.  The  layers  of  the  mesoeaecum  are  but 
loosely  adherent  to  each  other  and  may  be  readily  separated.  The 
caecum  is  continued  upward  into  the  ascending  colon  without  any 
definite  line  of  separation  between  them. 

The  Veemifokm  Appendix  is  a  blind,  worm-like  process,  which 
is  given  off  from  the  inner  posterior  aspect  of  the  caecum  at  the 


286  ABDOMEN  AND  BACK. 

point  where  the  longitudinal  bands  meet  and  from  one  to  one  and 
one-half  inches  below  the  junction  of  the  small  intestine  with  the 
caecuin.  It  is  found  lying  more  or  less  free  in  the  abdominal  cavity 
or  dipping  into  the  pelvis. 

The  base  of  the  appendix  corresponds  to  a  point  on  the  abdom- 
inal wall  called  "McBurney's  point,"  which  is  located  two  inches  to 
the  inner  side  of  the  anterior  superior  iliac  spine,  upon  a  line  drawn 
from  the  anterior  superior  iliac  spine  to  the  umbilicus. 

The  appendix  varies  much  in  size;  it  is  usually  as  thick  around 
as  a  lead  pencil  and  its  average  length  is  four  inches;  it  varies  from 
two  to  six  inches  and  may  be  longer.  Usually  it  is  a  hollow  tube, 
its  canal  extending  as  far  as  its  tip;  at  times,  however,  the  canal 
does  not  extend  to  the  tip  or  may  be  absent  entirely.  Its  inner  sur- 
face is  lined  with  mucous  membrane.  The  appendix  is  an  intra- 
peritoneal structure,  being  completely  invested  by  the  peritoneum, 
and  in  nearly  all  cases  it  is  provided  with  a  mesentery  of  its  own. 
This  mesentery  is  a  little  fold  derived  from  the  under  layer  of  the 
mesentery  of  the  small  intestine  where  the  latter  enters  the  csecum; 
it  incloses  the  appendix  between  its  folds,  and  usually  extends  only 
part  way  down  to  the  tip,  leaving  the  lower  third  or  half  of  the 
appendix  free.  This  mesentery  gives  one  the  impression  of  being 
too  short,  causes  the  appendix  to  present  its  curled-up  appearance, 
serves  to  limit  its  range  of  movement,  and  holds  it  in  close  relation 
with  the  caecum.  That  part  of  the  appendix  which  is  unprovided 
with  mesentery  is  freely  movable,  and  in  those  cases  in  which  the 
mesentery  is  nearly  or  entirely  absent  the  appendix  enjoys  a  con- 
siderable range  of  motion.  In  most  cases  the  appendix  is  more  or 
less  fixed  to  the  caecum  and  to  the  posterior  abdominal  wall  through 
its  mesentery.  Its  position,  as  regards  the  caecum,  varies  in  different 
individuals;  most  commonly  it  is  found  lying  upon  the  inner  or  left 
side  of  the  caecum,  with  its  tip  behind  the  ileum  and  pointing  upward 
in  the  direction  of  the  spleen.  In  other  cases  it  lies  upon  the  outer  or 
right  side  of  the  caecum,  rather  behind  it,  its  tip  pointing  upward 
toward  the  liver;  again,  it  may  be  found  dipping  down  into  the 
pelvis  or  lying  across  the  front  of  the  caecum.  In  any  of  these  posi- 
tions it  may  be  more  or  less  fixed  either  naturally  or  by  adhesions. 

In  the  female  the  appendix  is  connected  with  the  broad  ligament 
by  a  thin  band,  the  so-called  appendiculo-ovarian  ligament. 

The  appendix  gets  its  arterial  supply  from  a  single  small  vessel 
derived  from  the  ileo-colic,  which  is  a  branch  of  the  superior  mesen- 


SUEGICAL  ANATOMY  OF  THE  LARGE  INTESTINE,  ETC.        287 

teric.  The  venous  return  is  through  a  corresponding  single  venous 
channel  which  empties  into  the  superior  mesenteric  vein.  These 
vessels  run  parallel  with  the  appendix  in  the  edge  of  the  mesentery 
between  its  two  layers;  when  the  mesentery  is  absent  they  are  found 
upon  the  surface  of  the  appendix,  beneath  its  serous  coat.  In  the 
female  the  appendix  receives  an  additional  vessel  through  the  ap- 
pendiculo-ovarian  ligament.  The  appendix  is  dependent  for  its 
nutrition  upon  this  very  limited  blood-supply,  and  no  doubt  this 
arrangement  is,  at  least  in  part,  responsible  for  the  readiness  with 
which  the  wall  of  the  appendix  becomes  necrotic  when  its  circulation 
is  disturbed. 

Occasionally  some  difficulty  may  be  experienced  in  finding  the 
appendix.  If  the  longitudinal  bands  upon  the  csecum  are  traced 
downward,  they  will  be  found  to  lead  directly  to  the  point  where  the 
appendix  is  given  off,  and  therefore  these  bands  are  good  guides  to 
tbe  root  of  the  appendix. 

Just  above  the  root  of  the  appendix  the  small  intestine  ter- 
minates by  entering  the  caecum;  it  enters  the  caecum  upon  its  left 
side.  The  opening  between  the  ileum  and  caecum  is  guarded  by  the 
ileo-caecal  valve.  This  valve  consists  of  two  folds  of  mucous  mem- 
brane containing  some  circular  muscular  fibers.  These  folds,  pro- 
jecting into  the  lumen  of  the  gut,  allow  the  contents  of  the  ileum 
to  pass  freely  into  the  caecum,  but  prevent  the  reverse.  Fluids  in- 
jected through  the  rectum,  into  the  large  intestine,  cannot  pass  into 
the  ileum  unless  this  valve  is  forced,  and  that  requires  enough  press- 
ure to  threaten  the  rupture  of  the  large  intestine. 

The  Ascending  Colon. — This  is  the  continuation  upward  of 
the  csecum.  It  lies  close  to  the  posterior  wall  of  the  abdomen.  The 
ascending  colon  has  no  mesentery,  and  is  only  partly  invested  by  the 
peritoneum,  which  is  absent  upon  its  posterior  surface.  The  ascend- 
ing colon  ascends  along  the  outer  border  of  the  right  kidney,  lying 
partly  upon  the  kidney,  from  which  it  is  separated  by  some  inter- 
posed loose  connective  tissue  and  fat  only.  Continued  upward  as 
far  as  the  under  surface  of  the  liver,  it  makes  a  turn — the  hepatic 
flexure — and  becomes  the  transverse  colon.  The  under  surface  of 
the  liver  shows  a  shallow  depression  corresponding  to  the  hepatic 
flexure,  and  here  the  colon  is  attached  to  the  liver  by  a  reflection  of 
peritoneum,  the  ligamentum  hepatico-colicum. 

The  Transverse  Colon  stretches  from  right  to  left  across  the 
upper  part  of  the  abdominal  cavity,  lying  below  the  first  part  of  the 


2S8  ABDOMEN  AND  BACK. 

duodenum  and  greater  curvature  of  the  stomach.  Close  to  the 
spleen,  on  the  left  side,  the  colon  makes  a  second  turn, — the  splenic 
flexure, — and  from  this  point  is  continued  downward  as  the  descend- 
ing colon.  At  the  splenic  flexure  the  colon  is  fixed  to  the  diaphragm 
by  a  fold  of  peritoneum,  the  ligamentum  phrenico-colicum. 

The  transverse  colon  is  completely  invested  by  peritoneum  and 
has  a  long  mesentery  which  suspends  it  from  the  posterior  wall  of 
the  abdomen.  The  transverse  colon  enjoys  considerable  freedom  of 
movement,  but  is  connected  with  the  greater  curvature  of  the  stom- 
ach by  the  peritoneum. 

In  the  very  young  child  the  connection  of  the  transverse  colon 
to  the  greater  curvature  of  the  stomach  does  not  exist,  because  the 
layers  of  peritoneum  which  invest  the  stomach  and  unite  with  each 
other  at  the  greater  curvature  to  form  the  great  omentum  have  not 
become  adherent  to  the  peritoneum  which  envelops  the  transverse 
colon;  this  does  not  occur  until  later  in  life  (see  Fig.  90). 

The  Descending  Colon  passes  downward  in  the  left  side  of 
the  abdominal  cavity,  lying  close  to  its  posterior  wall,  to  which  it  is 
partly  fixed.  It  has  no  mesentery,  is  only  partly  invested  by  the 
peritoneum,  and  cannot  be  drawn  out  upon  the  abdomen.  The  poste- 
rior wall  of  the  descending  colon,  which  is  devoid  of  peritoneum, 
lies  close  to  the  outer  border  of  the  left  kidney,  lying  partly  upon 
its  anterior  surface.    It  is  continued  below  into  the  sigmoid  flexure. 

The  Sigmoid  Flexure  is  the  last  part  of  the  colon;  it  is  a 
redundant  loop  of  gut  curved  upon  itself  and  lying  in  the  left  iliac 
fossa.  Its  caliber  is  rather  smaller  than  that  of  the  other  parts  of 
the  colon;  it  is  completely  invested  by  the  peritoneum,  and  has  a 
fairly  long  mesentery,  which  suspends  it  to  the  posterior  abdominal 
wall  and  permits  of  much  freedom  of  motion.  It  may  be  freely 
drawn  out  upon  the  abdominal  wall.  At  the  sacro-iliac  synchondrosis 
it  is  continued  down  into  the  pelvis  as  the  rectum. 

The  Blood-supply  op  the  Large  Intestine. — The  caecum, 
appendix,  and  ascending  and  transverse  colon  are  supplied  by 
branches  which  are  given  off  from  the-  right,  or  concave,  side  of  the 
superior  mesenteric  artery. 

The  descending  colon  and  sigmoid  flexure  are  supplied  by  the 
inferior  mesenteric,  which  comes  off  from  the  front  of  the  aorta  just 
below  the  origin  of  the  superior  mesenteric;  after  supplying  the 
parts  mentioned  this  vessel  dips  into  the  pelvis,  between  the  layers 
of  the  mesorectum,  to  supply  the  rectum  as  far  as  its  lower  end. 


OPERATIONS  UPON  THE  LARGE  INTESTINE.  289 

The  arterial  branches  which  are  derived  from  the  superior  and 
inferior  mesenteric  for  the  supply  of  the  ascending  and  descending 
colon,  as  they  pass  to  their  destination,  lie  upon  the  posterior  abdom- 
inal wall  covered  by  the  peritoneum  which  lines  the  back  of  the 
abdomen;  those  which  supply  the  caecum,  transverse  colon,  and  sig- 
moid flexure,  which  parts  of  the  large  intestine  are  provided  with  a 
mesentery,  reach  their  destination  between  the  layers  of  the  mesen- 
tery corresponding  to  the  part. 

The  veins  have  a  course  similar  to  the  corresponding  arteries. 
The  inferior  mesenteric  joins  with  the  splenic  vein,  which,  in  turn, 
unites  with  the  superior  mesenteric  to  form  the  portal;  hence,  blood 
from  the  intestinal  tract  and  rectum1  must  first  traverse  the  portal 
circulation  (through  the  liver)  before  entering  the  general  circula- 
tion. Poisonous  matter  from  the  intestinal  tract  (colitis,  hemor- 
rhoids, etc.)  may  cause  thrombosis  in  the  veins  leading  from  these 
parts  or  abscess  in  the  liver,  etc. 

As  is  the  case  with  the  vessels  of  the  small  intestine,  the  ter- 
minals of  the  arteries  that  are  distributed  to  the  large  intestine  do 
not  anastomose  freely;  hence  division  of  a  considerable  branch  will 
often  result  in  gangrene  of  the  corresponding  part  of  the  gut. 


OPERATIONS  UPON  THE  LARGE  INTESTINE. 

Colostomy. — The  formation  of  a  fistulous  opening  into  the  large 
intestine,  a  so-called  artificial  anus.  It  is  performed  for  obstruction 
in  the  large  intestine  or  rectum  or  as  a  preliminary  to  extirpation 
of  the  rectum.  This  operation  may  be  done  to  save  life  when  the 
danger  is  imminent  and  the  nature  of  the  lesion  or  the  patient's 
general  condition  precludes  the  probability  of  doing  a  radical  opera- 
tion with  a  reasonable  likelihood  of  success.  At  times  one  does  not 
decide  upon  the  formation  of  an  artificial  anus  until  after  an  ex- 
ploratory laparotomy  shows  its  necessity. 

Unless  one  can  previously  locate  the  seat  of  the  obstruction,  the 
exploratory  incision  is  best  placed  in  the  middle  line,  between  the 
umbilicus  and  the  symphysis,  and  the  artificial  anus  made  by  bring- 
ing the  most  accessible  portion  of  the  large  intestine  into  this  same 
incision  and  fixing  it  there.     The  bowel  above  (proximal  to)  the  ob- 


1  Some  venous  blood  from  the  rectum  enters  the  general  circulation  direct  through 
the  middle  and  inferior  hemorrhoidal  veins. 

19 


290  ABDOMEN  AND  BACK. 

struction  is  found  distended,  and  that  below  (distal),  diminished  in 
caliber  or  collapsed. 

Descending  Colon. — If  the  obstruction  can  be  located  in  the 
sigmoid  flexure  or  rectum,  the  abdomen  is  opened  in  the  left  iliac 
region  and  the  lower  part  of  the  descending  colon  is  brought  up  into 
the  wound  and  fixed  to  its  edges. 

An  incision  about  three  inches  long  usually  suffices;  it  is  made 
slightly  oblique  from  above  downward  and  inward,  corresponding  to 
the  linea  semilunaris,  the  middle  of  the  incision  being  upon  a  line 
drawn  from  the  umbilicus  to  the  anterior  superior  spinous  process. 

The  incision  is  carried  through  the  layers  of  the  abdominal  wall 
until  the  parietal  peritoneum  is  reached.  After  bleeding  points  have 
been  clamped  the  peritoneum  is  caught  up  with  two  mouse-toothed 
forceps,  and  between  them  a  small  opening,  large  enough  to  admit 
the  finger,  is  made  with  the  knife.  This  opening  is  enlarged  upon 
the  finger  with  a  blunt-pointed  scissors  so  as  to  correspond  in  length 
with  the  incision  in  the  skin. 

The  edge  of  the  peritoneum,  upon  each  side,  is  then  fixed  to 
the  corresponding  margin  of  the  skin,  near  the  middle,  with  two  or 
three  catgut  sutures  (E,  Fig.  127);  this  is  done  to  prevent  retraction 
of  this  layer  of  peritoneum. 

Instead  of  placing  the  incision  as  indicated  above  it  may  be  made 
nearer  the  middle  line,  so  as  to  pass  between  the  fibers  of  the  rectus 
muscles,  separating  between  these  bluntly  with  the  handle  of  the  knife. 
This  may  give  an  artificial  anus  which  is  less  difficult  to  control. 

A  silk  stitch  (A,  Fig.  127)  is  now  passed  through  the  edges  of 
the  upper  part  of  the  incision,  through  all  the  layers,  including  the 
skin  and  the  edges  of  the  peritoneum;  a  second  similar  suture  (D, 
Fig.  127)  is  passed  through  the  lower  part  of  the  incision.  These 
two  sutures  are  not  tied.  The  lower  part  of  the  descending  colon 
is  now  sought  and  brought  up  into  the  wound.  In  order  to  secure 
this  two  fingers  are  introduced  into  the  abdomen  and  carried  out- 
ward and  backward,  along  the  inner  aspect  of  th*e  abdominal  wall, 
as  far  as  the  lumbar  region,  where  the  colon  is  found;  one  may 
meet  with  coils  of  the  small  intestine,  and  these  may  get  in  the 
way  of  the  hand,  but  they  may  be  recognized  as  being  entirely  sur- 
rounded by  peritoneum  and  easily  pushed  aside;  the  fingers  are 
then  allowed  to  glide  from  the  posterior  wall  of  the  abdomen  on  to 
the  colon.  The  sigmoid  flexure  should  not  be  brought  up  into  the 
wound  by  mistake  for  the  descending  colon,  because  this  part  of  the 


OPERATIONS  UPON  THE  LARGE  INTESTINE. 


291 


gut  has  such  a  long  mesentery  that,  if  used  to  form  the  artificial  anus, 
it  may  after  a'  time  become  very  much  prolapsed,  and  this  is  unde- 
sirable. Having  secured  the  descending  colon,  we  select  a  portion 
sufficiently  high  up  as  to  just  allow  of  it  being  conveniently  drawn 
into  the  wound.  If  it  can  be  readily  drawn  out  upon  the  abdomen 
we  may  know  that  we  have  the  sigmoid  flexure,  and  we  should  then 
select  a  portion  of  the  gut  above  this. 


<S) 


Fig.  127. — Colostomy.  The  wall  of  the  descending  colon  drawn  into  the 
incision  and  fixed.  A,  D,  stitches  which  pass  through  all  the  layers  of  the 
abdominal  wall,  including  the  peritoneum;  B,  C,  stitches  which  pass  through 
all  the  layers  of  the  abdominal  wall,  including  the  peritoneum,  but  catch  up 
the  wall  of  the  gut  as  well  in  their  course;  E,  stitches  that  join  the  parietal 
peritoneum  to  the  skin. 


While  that  part  of  the  gut  which  has  been  selected  is  steadied 
in  the  wound,  a  silk  stitch  (B,  Fig.  127)  in  a  curved  surgeon's  needle 
is  passed  through  the  upper  part  of  one  edge  of  the  incision,  through 
all  the  layers,  care  being  taken  to  include  the  peritoneum;  it  then 
passes  superficially  through  the  wall  of  the  gut,  picking  up  its  serous 
and  muscular  coats  and  taking  a  good,  broad  bite,  but  not  penetrat- 


292  ABDOMEN  AND  BACK. 

ing  into  its  lumen,  and  finally  through  the  opposite  edge  of  the  ab- 
dominal incision.  A  second  stitch  (C,  Fig.  127)  is  similarly  introduced 
in  the  lower  part  of  the  abdominal  wound,  and  this  also  catches  the 
wall  of  the  bowel  on  the  way.  These  two  stitches  (B  and  C)  should 
be  about  two  inches  apart;  they  are  now  tied,  likewise  the  two 
stitches  previously  introduced  through  the  edges  of  the  wound,  above 
and  below,  and  the  bowel  is  thus  partially  fixed  in  the  abdominal 
incision. 

The  bowel  is  now  still  further  fixed  to  the  margins  of  the  ab- 
dominal incision  by  three  or  four  interrupted  fine  silk  sutures  on 
either  side;  each  one  of  these  should  secure  the  serous  and  muscular 
coats  of  the  bowel  and  the  edge  of  the  incision  in  the  abdomen,  in- 
cluding the  parietal  peritoneum  and  skin. 

If  the  condition  is  not  very  urgent,  the  bowel  had  better  not  be 
opened  until  after  the  lapse  of  forty-eight  hours,  thus  allowing  time 
for  adhesions  to  form  and  shut  off  the  peritoneal  cavity.  If  it  is 
necessary  to  open  the  bowel  at  once  a  few  more  extra  sutures  should 
be  taken  in  order  to  secure  as  accurate  a  union  as  possible  between 
the  surface  of  the  bowel  and  edges  of  the  abdominal  incision. 

The  opening  in  the  bowel  may  be  made  with  a  knife,  the  bowel 
being  held  between  two  forceps,  or  it  may  be  made  with  a  Paquelin 
cautery;  it  should  be  sufficiently  large  to  allow  the  introduction  of 
a  fairly  thick,  snugly-fitting  tube.  Iodoform  gauze  is  packed  well 
about  this  tube  in  dressing  the  wound. 

Matdl  Method.  —  An  incision  is  made  as  above  and  two  or 
three  interrupted  catgut  sutures  are  introduced  on  each  side,  which 
serve  to  fix  the  parietal  peritoneum  to  the  skin  {E,  Fig.  128).  "  A 
silk  suture  (A  and  D,  Fig.  128)  is  also  introduced  in  the  upper  and 
lower  ends  of  the  incision.  These  are  left  untied  until  the  coil  of 
gut  has  been  secured  and  are  simply  for  the  purpose  of  diminishing 
the  size  of  the  incision.  A  convenient  portion  of  the  gut  is  then 
seized  and  drawn  out  through  the  abdominal  incision  and  a  glass 
cylinder  or  an  artery  forceps  or  a  strip  of  gauze  is  thrust  through  its 
mesentery  and  placed  at  right  angles  to  the  incision  in  the  abdomen, 
so  as  to  retain  the  loop  of  gut  in  situ,  outside  the  abdomen,  until 
adhesions  have  had  time  to  form.  The  loop  of  gut  may  be  still 
further  secured  by  fixing  it  to  the  edges  of  the  incision  with  several 
catgut  sutures.  The  gut  is  then,  subsequently,  divided  completely 
through,  down  to  the  glass  cylinder  or  forceps. 

If  a  portion  only  of  the  wall  of  the  bowel  is  fixed  to  the  opening 


OPERATIONS  UPON  THE  LARGE  INTESTINE. 


293 


in  the  abdomen,  as  described  in  the  first  operation,  there  is  permitted 
ready  escape  of  the  contents  of  the  bowel,  but,  at  the  same  time,  the 
possibility  of  some  of  the  contents  passing  onward,  into  the  lower 
segment,  is  not  precluded.  This  condition  is  easily  restored  to  the 
normal,  so  that  this  method  of  operating  is  preferable  unless  we 


Fig.  128.— Colostomy  (Maydl).  A  whole  locp  of  large  intestine  has  been 
drawn  out  of  the  abdomen  and  a  glass  rod  thrust  through  its  mesentery  to 
prevent  its  returning.  A,  D,  sutures  that  penetrate  all  the  layers  of  the 
abdominal  wall  and  serve  simply  to  diminish  size  of  the  wound.  E,  E, 
sutures  that  join  the  edges  of  the  peritoneum  to  the  skin. 


desire  the  artificial  anus  to  remain  permanently.  On  the  other  hand, 
if  a  whole  knuckle  of  gut  is  brought  out  of  the  wound,  as  described 
in  the  second  (Maydl)  operation,  a  "spur"  is  formed  which  acts  as 
a  valve,  directing  the  bowel  contents  out  through  the  opening  upon 
the  abdomen,  and  at  the  same  time  hindering  the  passage  of  any 


294 


ABDOMEN  AND  BACK. 


Fig.  129.— Colostomy.  Antero-posterior  section  shows  the  wall  of  the  colon 
drawn  into  the  incision  in  the  abdomen.  C,  colon;  S,  symphysis  pubis;  V, 
umbilicus. 


Fig.  130. — Colostomy  (Maydl).  An  antero-posterior  section  showing  a 
whole  loop  of  intestine  drawn  out  of  the  incision  in  the  abdomen.  The  ap- 
posed walls  of  the  loop  become  joined  to  each  other  by  adhesion,  and  thus 
a  spur,  or  partition,  is  formed  which  prevents  the  contents  of  the  upper  part 
of  the  gut  entering  the  lower  portion.     C,  S,  U,  same  as  Fig.  129. 


OPERATIONS  UPON  THE  LARGE  INTESTINE.  295 

part  of  the  bowel  contents  onward  into  the  lower  segment;  it  also 
insures  the  permanency  of  the  artificial  anus. 

Ascending  Colon. — If  the  growth — obstruction — involves  the 
transverse  or  descending  colon,  the  operation  may  be  performed  in 
a  similar  manner  upon  the  right  side  of  the  body;  in  this  case  the 
lower  part  of  the  ascending  colon  is  brought  into  the  wound  and 
fixed. 

Resection  of  the  Caecum. — This  may  include,  in  addition  to  the 
caecum,  the  whole  or  a  part  of  the  ascending  colon  and  part  of  the 
ileum.     For  malignant  disease,  tuberculosis,  and  intussusception. 

If,  before  operating,  the  disease  can  be  located  in  this  part  of 
the  gut  or  a  tumor  felt,  the  incision  is  probably  best  placed  directly 
over  the  tumor  along  the  outer  border  of  the  right  rectus  muscle, 
in  the  linea  semilunaris.  If  the  incision  is  made  for  the  purpose  of 
exploration,  it  is  usually  placed  in  the  middle  line,  reaching  from 
the  umbilicus  down,  toward  the  symphysis;  through  this  incision, 
however,  the  caecum  may  also  be  excised  if  found  advisable.  In  either 
case  the  incision  must  be  long  enough  to  allow  sufficient  room  for 
work. 

If  the  incision  is  made  along  the  outer  border  of  the  rectus  it 
should  commence  about  one  inch  above  the  middle  of  Poupart's 
ligament  and  is  carried  in  a  direction  upward  to  a  point  located  mid- 
way between  the  umbilicus  and  the  anterior  superior  iliac  spine  or,  if 
necessary,  it  may  be  continued  farther  upward  toward  the  tip  of  the 
tenth  rib.  It  may  vary  from  five  to  ten  inches  in  length.  Having 
penetrated  through  the  abdominal  wall  down  to  the  parietal  perito- 
neum, this  layer  is  picked  up  with  two  toothed  forceps  and  incised 
between  them.  We  may  then  find  it  necessary  to  separate  some  ad- 
hesions before  the  cascum  is  exposed.  This,  together  with  the  ad- 
joining portion  of  the  ileum,  is  then  brought  out  of  the  incision  upon 
the  abdomen. 

If  the  caecum  is  the  seat  of  malignant  disease  and  already  so 
fixed  within  the  abdomen  that  it  cannot  be  brought  out  of  the  wound, 
it  is  probably  inadvisable  to  proceed  with  the  extirpation,  because,  if 
one  is  not  reasonably  certain  of  removing  all  the  diseased  tissue,  the 
risk  is  probably  out  of  proportion  to  the  best  result  that  can  be 
hoped  for. 

The  cascum,  being  steadied  outside  the  abdominal  incision,  is 
surrounded  by  gauze  pads  to  protect  the  abdominal  cavity,  and  two 
strips  of  gauze  are  tied  about  the  intestine  beyond  the  part  which 


296  ABDOMEN  AND  BACK. 

is  to  be  excised.  Before  tying  the  second  piece  of  gauze  the  seg- 
ment of  gut  may  be  emptied  by  stripping  it  between  the  fingers.  The 
gauze  strips  should  be  placed  well  beyond  the  limits  of  the  part  to 
be  excised,  and  may  be  carried  around  the  gut  in  the  mouth  of  a 
sharp-nosed  artery  forceps  which  is  thrust  through  its  mesentery. 

The  mesentery,  corresponding  to  the  segment  of  gut  which  is 
to  be  excised,  is  tied  off  in  sections  with  catgut  ligatures.  The  liga- 
tures may  be  carried  in  the  eye  of  a  blunt  ligature  carrier  or  with 
a  pointed-nosed  artery  forceps.  Each  ligature  should  be  single  and 
placed  some  distance  away  from  the  gut,  so  as  to  leave  space  to  cut 
between  them  and  the  gut.  The  segment  of  gut  which  is  to  be  ex- 
cised is  detached  by  cutting  the  mesentery  between  the  ligatures  and 
the  gut.  One  should  take  care  to  excise  all  of  the  gut  whose  mesen- 
tery has  been  tied  off,  because,  if  an  end  of  the  gut  which  has  been 
deprived  of  its  mesentery  is  left,  it  is  likely  to  become  gangrenous. 
It  now  remains  to  divide  the  gut  above  and  below  and  remove  the 
diseased  segment.  This  is  done  with  a  long,  straight  scissors  in  one 
sweep,  long  clamps  having  been  previously  placed  upon  the  gut 
close  to  the  diseased  segment  in  order  to  prevent  the  escape  of  its 
contents  when  it  is  cut. 

Instead  of  proceeding  as  above,  one  may,  after  the  strips  of 
gauze  and  clamps  have  been  applied  about  the  gut,  excise  the  dis- 
eased segment  and  then  tie  off  the  corresponding  part  of  the  mesen- 
tery in  sections  as  already  described. 

We  are  now  ready  for  the  final  step  of  the  operation,  the  restora- 
tion of  the  continuity  of  the  alimentary  canal  by  joining  the  ileum 
to  the  colon  (ileo-colostomy),  and  this  may  be  accomplished  by: — 

1.  End-to-end  anastomosis  (with  suture  or  Murphy  button). 

2.  Lateral  anastomosis  (with  suture  or  McGraw's  rubber  liga- 
ture or  Laplace  or  O'Hara  forceps,  etc.). 

3.  Lateral  implantation  (with  suture  or  Murphy  button). 
End-to-End  Anastomosis. — This  method  may  be  employed  if 

both  ends  of  the  gut  which  are  to  be  united  are  of  the  same  caliber; 
this  condition  at  times  exists,  owing  to  the  fact  that  the  obstruction 
in  the  caecum  or  at  the  ileo-caecal  opening  may  have  caused  a  dilata- 
tion and  hypertrophy  of  the  ileum,  the  large  intestine  at  the  same 
time  having  become  more  or  less  diminished  in  caliber.  The  anas- 
tomosis is  made  with  a  double  row  of  silk  sutures,  the  first  row  pass- 
ing through  all  the  layers  of  the  wall  of  the  intestine,  including  the 
mucous  membrane  and  serous  layers,  and  applied  in  such  a  manner 


OPERATIONS  UPON  THE  LARGE  INTESTINE.  297 

that  the  sutured  edges  are  inverted  inward  into  the  lumen  of  the 
gut;  this  first  row  of  sutures  may  he  continuous  and  applied  with 
a  medium-sized  curved  surgeon's  needle.  The  second  row  of  sutures 
(Lemhert)  is  passed  through  the  serous  and  muscular  coats  only, — ■ 
they  do  not  penetrate  into  the  lumen  of  the  bowel, — and  serve  to 
bury  the  first  row.  This  second  row  may  also  be  continuous.  In 
applying  both  of  these  rows  great  care  should  be  exercised  to  include 
the  serous  coat,  especially  near  the  mesenteric  attachment.  This  is 
the  weak  spot,  especially  in  suturing  the  large  intestine. 

The  end-to-end  anastomosis  may  also  be  made  with  a  Murphy 
button  of  largest  size. 

Lateral  Anastomosis. — This  is  a  satisfactory  method  of  re- 
storing the  continuity  of  the  intestinal  canal,  particularly  if  the  ends 
are  of  unequal  size;  for  example,  in  joining  the  ileum  to  the  esecum 
or  colon. 

The  cut  edge  of  each  segment  of  gut  is  inverted,  a  margin  of 
three-fourths  to  one  inch  being  turned  in  and  the  opening  closed  with 
a  continuous  silk  stitch,  which  passes  through  the  serous  and  muscu- 
lar coats,  always  taking  special  care,  particularly  at  the  mesenteric 
border,  to  appose  serous  surfaces  to  each  other.  A  second  continuous 
silk  suture  is  then  introduced;  this  second  suture  also  includes  only 
the  serous  and  muscular  coats  and  serves  to  bury  the  first  line  of 
suture.  The  ends  of  the  bowel  which  have  been  thus  closed  up  are 
now  placed  side  to  side,  overlapping  each  other  for  a  distance  of  five 
or  six  inches,  and  they  are  then  united,  surface  to  surface,  for  a  dis- 
tance of  four  or  five  inches  with  a  continuous  Lembert  suture  of  fine 
silk.  This  forms  the  first  half  of  the  "outside  serous  ring"  suture, 
and  when  completed  the  needle,  with  the  suture  left  long,  is  tem- 
porarily laid  aside. 

An  incision  is  then  made  in  each  segment  of  the  gut  three  to 
four  inches  long,  but  not  so  long  as  the  line  of  the  Lembert  suture 
(one  inch  shorter),  and  at  a  distance  of  about  one-fourth  inch  away 
from  the  line  of  the  Lembert  suture.  The  corresponding  edges  of 
these  incisions  are  then  joined  together  all  around  with  a  continuous 
overhand  silk  or  catgut  suture,  which  includes  all  the  coats  of  the 
gut  and  which  may  be  introduced  with  a  large,  straight  needle. 
After  the  edges  of  these  openings  have  been  thus  united,  the  needle 
with  which  the  first  half  of  the  "outside  serous  ring"  suture  was 
made  is  again  taken  up  and  the  second  half  of  the  "outside  serous 
ring,"  Lembert  suture,  inserted.    The  gut  may  be  kept  free  of  con- 


-298  ABDOMEN  AND  BACK. 

tents  during  the  operation,  as  usual,  by  strips  of  gauze  passed  around 
each  segment  of  gut  beyond  the  site  of  the  operation.  The  margins 
of  the  gut  may  be  wiped  off  with  a  moist  bichloride  pad  as  often  as 
they  are  soiled  by  escaping  intestinal  contents. 

Having  completed  the  union  of  the  two  segments  of  gut,  any 
rent  or  opening  which  is  left  in  the  mesentery  may  be  closed  by  sev- 
eral catgut  sutures  and  the  parts  returned  to  the  abdomen. 

The  lateral  anastomosis  may  also  be  made  with  McGraw's  rubber 
ligature  in  a  manner  analogous  to  that  described  in  gastroenteros- 
tomy or  with  the  Laplace  or  O'Hara  forceps. 

End-to-Side,  Lateeal  Implantation. — Analogous  to  Kocher's 
gastro-duodenostomy  (see  "Pylorectomy").  This  is  probably  not  as 
satisfactory  a  procedure  as  either  of  the  preceding  methods.  It  may 
be  done  by  suture  or  with  a  Murphy  button. 

After  closing  the  end  of  the  large  intestine  the  end  of  the  ileum 
is  united  to  the  edges  of  a  slit  which  is  made  in  the  large  intestine 
opposite  its  mesenteric  border,  the  union  being  accomplished  either 
by  suture  or  with  a  Murphy  button  (see  "Pylorectomy"). 

By  any  of  these  means  the  ileum  may  be  joined  to  any  part  of 
the  large  intestine.  Owing  to  the  frequent  imperfections  of  the 
serous  coat  at  the  mesenteric  border  of  the  large  intestine,  the  suture 
in  all  these  operations  is  always  somewhat  doubtful,  and  it  may  be 
wise  in  many  cases  to  leave  a  strand  of  gauze,  reaching  from  the 
sutured  gut  through  the  abdominal  incision,  for  drainage  in  case  of 
leakage. 

Ileo-colostomy  Without  Resection  of  the  Caecum  or  Colon. — This 
operation  may  be  done  in  cases  of  obstruction  at  the  ileo-caecal  valve 
when  the  advisability  of  a  more  radical  operation — resection — is 
doubtful.  An  anastomosis  may  thus  be  made  between  the  ileum  and 
the  ascending  colon,  or,  if  the  obstruction  is  located  in  another  part 
of  the  colon,  the  anastomosis  may  be  made  between  the  ileum  and 
the  sigmoid  flexure.  Care  should  be  taken  to  secure  a  coil  of  small 
intestine  as  low  down,  near  the  caecum,  as  possible;  so  that  the 
nutrition  of  the  patient  may  not  be  seriously  interfered  with. 

Resection  of  the  Sigmoid  Flexure. — This  operation  is  usually 
performed  for  malignant  obstruction.  This  part  of  the  large  intes- 
tine is  a  favorite  seat  of  malignant  disease. 

The  incision  is  probably  best  made  analogous  to  that  for  ex- 
cision of  the  cascum,  but  upon  the  other  side  of  the  abdomen,  along 
the  outer  border  of  the  left  rectus,  commencing  below,  about  one 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.  299 

inch  above  the  middle  of  Poupart's  ligament.  The  sigmoid  may  also 
be  resected  through  an  incision  in  the  linea  alba,  extending  from 
the  umbilicus  downward  to  the  symphysis  pubis  if  such  an  incision 
has  been  already  made  for  the  purpose  of  exploration  before  the 
growth  was  definitely  located. 

The  sigmoid,  owing  to  its  long  mesentery,  may  be  readily  drawn 
out  through  the  abdominal  incision.  It  is  surrounded  by  gauze  pads 
to  protect  the  abdominal  cavity,  and  after  the  mesentery,  which  is 
usually  quite  long,  has  been  tied  off  in  sections,  that  part  of  the  bowel 
which  is  to  be  resected  is  clamped  off,  cut  free  from  its  mesenteric 
-attachment,  and  finally  excised.  The  ends  of  the  bowel  are  then 
united,  end  to  end,  by  suture  or  with  a  large  Murphy  button.  The 
.same  care,  etc.,  should  be  exercised  in  suturing  near  the  mesenteric 
.attachment  to  include  the  serous  coats.  After  resection  of  the  sig- 
moid each  end  of  the  bowel  may  be  inverted  and  closed  and  a  lateral 
anastomosis  done  as  already  described  in  connection  with  resection 
•of  the  caecum. 

If  the  sigmoid  is  fixed  and  the  neighboring  parts  already  infil- 
trated, it  may  be  better  to  make  an  artificial  anus  above  the  seat  of 
•obstruction  and  omit  the  radical  operation. 

The  colon  has  also  been  resected  at  the  hepatic  and  the  splenic 
flexures,  the  incision  being  made  above,  along  the  outer  border  of 
the  corresponding  rectus,  or  in  the  middle  line,  from  the  ensiform 
-cartilage  downward  to  or  beyond  the  umbilicus.  The  continuity  of 
the  canal  may  be  restored  by  any  one  of  the  methods  described  above. 

OPERATIONS  UPON  THE  VERMIFORM  APPENDIX. 

Appendicectomy. — Eemoval  of  the  appendix. 

As  performed  in  cases  of  chronic  relapsing  catarrhal  and  re- 
-current  appendicitis,  there  being  no  abscess  present.  In  these  cases 
the  incision  in  the  abdomen  is  closed  immediately  upon  completion 
•of  the  operation  and  without  drainage. 

The  Incision"  is  oblique  from  above,  downward  and  inward,  and 
should  be  about  three  inches  long.  Some  operators  use  a  much 
shorter  incision:  Morris,  one  and  one-half  inches.  The  incision 
«hould  be  sufficiently  long  to  allow  proper  performance  of  the  opera- 
tion. It  is  well  to  commence  with  a  short  incision,  which  may  be 
lengthened  later  should  it  become  necessary. 

The  incision  should  be  placed  about  one  and  one-half  inches  to 


300  ABDOMEN  AND  BACK. 

the  inner  side  of  the  anterior  superior  iliac  spine,  crossing,  almost 
at  a  right  angle,  a  line  drawn  from  the  anterior  superior  spine  to  the 
umbilicus  and  so  arranged  that  one-third  of  its  length  is  above  the 
line  and  two-thirds  below  it. 

All  bleeding  points  should  be  clamped,  but  need  not  be  ligated 
immediately,  as  they  usually  stop  after  the  forceps  have  been  applied 
for  a  few  minutes.  The  aponeurosis  of  the  external  oblique  is  ex- 
posed and  divided,  separating  between  its  fibers  along  a  line  corre- 
sponding to  the  skin  incision.  The  muscular  fibers  of  the  internal 
oblique  are  then  exposed  and  incised,  together  with  those  of  the 
transversalis,  which  muscle  lies  beneath  the  internal  oblique;  the 
fibers  of  these  muscles  are  divided  at  right  angles  to  their  course. 
Finally  the  incision  is  carried  through  the  fascia  transversalis  and 
parietal  peritoneum,  the  latter  being  picked  up  with  two  mouse- 
toothed  forceps  and  divided  between  these.  The  gut  as  it  lies  be- 
neath the  peritoneum  may  be  adherent  to  the  latter,  and  therefore 
care  should  be  exercised  in  cutting  through  the  peritoneum  not  to 
wound  the  gut.  It  may  not  be  necessary  to  divide  the  muscles  for 
the  whole  length  of  the  skin  incision.  In  many  cases,  if  the  mus- 
cular layer  is  divided  for  a  distance  corresponding  to  the  middle  half 
of  the  length  of  the  skin  incision,  this  will  suffice,  and,  if  necessary,, 
later  the  incision  in  the  muscles  can  be  lengthened  above  and  below. 

In  closing  this  incision  each  layer  should  be  united  separately:, 
first,  the  parietal  peritoneum  with  a  continuous  catgut  stitch;  then 
the  transversalis  fascia  and  the  muscles  with  a  second  continuous 
catgut  stitch;  then  the  aponeurosis  of  the  external  oblique,  also 
with  a  continuous  catgut  suture;  and  finally  the  skin,  with  a  catgut 
stitch.  The  incision  in  the  skin  may  be  closed  with  an  intracutieular 
suture. 

The  McBurney  Gridiron  Incision.  —  The  cut  through  the 
skin  is  the  same  as  that  described  in  the  preceding  paragraphs;  the 
aponeurosis  of  the  external  oblique  is  split  by  separating  between 
its  fibers,  and  then  two  broad,  sharp  retractors  are  introduced,  and, 
retracting  the  skin  and  aponeurosis,  the  muscular  fibers  of  the  in- 
ternal oblique  are  exposed;  these  are  not  cut,  but  are  separated  with 
the  handle  of  the  knife  in  the  direction  of  the  fibers,  which  is  nearly 
at  a  right  angle  to  the  direction  of  the  skin  incision.  The  fibers  of 
the  transversalis  muscle  are  next  exposed  and  treated  in  a  similar 
manner.  Two  broad,  blunt  retractors  are  now  introduced  and  the 
edges  of  the  muscles  drawn  apart,  when  the  transversalis  fascia  is. 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.  301 

exposed  and  incised,  and  finally  the  peritoneum.  These  last  two 
layers  are  divided  in  the  same  direction  as  the  internal  oblique;  i.e., 
at  right  angles  to  skin  incision. 

Two  sets  of  retractors  are  necessary  to  hold  the  wound  open: 
one  set,  sharp,  for  the  edges  of  the  skin  and  aponeurosis  of  the  ex- 
ternal oblique,  retracting  from  side  to  side;  the  other  set*,  blunt, 
for  the  muscles  and  deeper  layers,  retracting  from  above  and  from 
below.  We  have  thus  a  four-sided  opening  in  the  abdomen  which 
may  be  enlarged  by  prolonging  the  separation  and  incision  in  the 
different  layers. 

In  closing  this  incision  the  edges  of  the  peritoneum  are  first 
brought  together  with  a  continuous  catgut  stitch.  The  edges  of  the 
muscles  of  themselves  return  to  place  and  are  secured  by  two  or 
three  interrupted  catgut  sutures,  which  include  the  transversalis 
fascia  also  in  their  bite.  The  aponeurosis  of  the  external  oblique  is 
sewed  with  a  continuous  catgut  suture  from  above  downward,  and 
the  skin  then  closed  with  an  intracuticular  catgut  suture. 

There  being  no  muscles  or  aponeurotic  fibers  cut,  the  liability 
to  hernia  is  very  much  diminished. 

The  Battle  Incision. — A  perpendicular  incision,  four  inches 
in  length,  which  is  placed  one  and  one-half  inches  to  the  inner  side 
of  the  linea  semilunaris,  is  made  through  the  skin  and  fat,  down  to 
the  aponeurosis  of  the  external  oblique.  The  lower  two-thirds  of 
this  incision  should  be  below  a  line  which  is  drawn  from  the  anterior 
superior  spine  to  the  umbilicus.  The  aponeurosis,  which  really  forms 
the  anterior  layer  of  the  sheath  of  the  rectus,  is  then  divided  to  cor- 
respond with  the  skin  incision  and  the  fibers  of  the  rectus  thus  ex- 
posed. The  rectus  muscle  is  not  cut,  but  is  drawn  inward  until  its 
outer  edge  is  reached,  and,  while  it  is  thus  held  with  a  blunt  re- 
tractor, the  posterior  layer  of  its  sheath  is  incised  for  a  length  corre- 
sponding with  the  incision  in  its  anterior  layer.  This  incision 
through  the  posterior  layer  of  the  rectus  sheath  is  not  placed  imme- 
diately behind  the  incision  in  the  anterior  layer,  but  rather  external 
to  it.  The  parts  being  well  retracted,  good  access  is  had  to  the  ab- 
dominal cavity. 

In  closing  this  opening  each  layer  is  sutured  separately:  first, 
the  peritoneum,  and  then  the  opening  in  the  posterior  layer  of  the 
sheath  of  the  rectus.  The  rectus  muscle  is  allowed  to  resume  its 
normal  position,  and  a  suture  is  placed  in  the  anterior  layer  of  its 
sheath.     These   sutures  are   all  continuous   and  of  simple   catgut; 


302  ABDOMEN  AND  BACK. 

finally  the  skin  incision  is  closed.  This  incision  also  diminishes  the 
liability  to  hernia. 

After  having  opened  into  the  abdomen  we  may  proceed  with 
the  next  step  of  the  operation,  the  search  for  the  appendix.  At  times 
it  may  be  found  presenting  at  once  in  the  wound,  more  or  less 
changed,  thickened,  etc.,  or,  occasionally  being  bound  down  and 
fixed  within  the  abdomen  by  adhesions,  it  does  not  come  into  view, 
and  then  it  will  be  necessary  to  search  for  it. 

The  appendix  may  be  directed  downward  and  may  dip  into  the 
pelvis,  or,  with  its  tip  pointed  upward,  it  may  lie  to  the  outer  or  to 
the  inner  side  of  the  caecum.  It  may  be  more  or  less  confined  in  any 
of  these  positions  by  its  mesentery  or  by  adhesions. 

If  difficulty  is  experienced  in  finding  the  appendix,  the  caecum 
may  be  brought  out  of  the  wound  to  serve  as  a  guide.  The  caecum 
may  be  identified  by  its  sacculation,  by  the  little  fatty  processes  at- 
tached to  it,  and  by  its  longitudinal,  white  striae,  two  of  which  can 
usually  be  seen:  if  these  striae  are  followed  they  will  be  found  to  lead 
down  to  the  point  where  the  appendix  is  given  off. 

The  appendix  is  gently  liberated  from  its  adhesions  with  the 
fingers, — there  is  no  danger  of  hemorrhage  in  this  procedure, — and 
gradually  it  is  brought  out  of  the  wound,  the  caecum  being  at  the 
same  time  returned  into  the  abdomen. 

It  is  wise,  before  beginning  to  free  the  appendix,  to  introduce 
into  the  wound  one  or  more  gauze  pads  to  protect  the  peritoneal 
cavity  during  the  removal  of  the  appendix  and  in  the  event  of  unex- 
pectedly meeting  a  small  collection  of  pus. 

After  the  appendix  has  been  sufficiently  freed  it  is  held  in  the 
wound  or  outside  the  abdominal  incision,  and  after  having  properly 
arranged  the  gauze  pads  so  as  to  protect  the  peritoneal  cavity,  we 
proceed  at  once  to  tie  off  the  mesentery  of  the  appendix.  This  is 
done  by  transfixing  the  mesentery  close  to  the  appendix  and  near  its 
root  with  a  ligature  carrier  or  with  a  straight  or  curved  needle  carry- 
ing a  loop  of  No.  2  simple  catgut.  This  ligature  is  tied  and  the 
appendix  then  cut  away  from  the  mesentery,  cutting  between  the 
appendix  and  the  ligature  with  the  scissors.  The  appendix  being 
thus  separated  from  its  mesentery,  we  are  ready  to  proceed  with  the 
final  step  of  the  operation, — the  removal  of  the  appendix.  This  may 
be  done  in  one  of  several  ways. 

1.  Ligatuee  Without  Inveksion. — After  the  mesentery  has 
been  tied  off  and  cut  away  from  the  appendix  with  the  scissors,  a 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX. 


303 


catgut  ligature  (jSTo.  2)  is  tied  tightly  around  the  appendix  about 
one-fourth  inch  distant  from  its  root;  the  ends  of  this  ligature  are 
left  long  to  serve  as  a  temporary  tractor.     The  appendix  is  then 


Fig.  131. — Appendix.     Meso-appendix  shown. 


seized  with  an  artery  clamp  upon  the  distal  side  of  the  ligature  to 
prevent  leakage  when  it  is  cut,  and  with  the  straight  scissors  it  is 
amputated  between  the  clamp  and  ligature.     While  the  stump  of 


132.—  Appendicectomy.     Appendix   (A)   ligated  without  inversion  and 
amputated;  M,  meso-appendix  tied  off. 


the  appendix  is  steadied  by  making  traction  with  the  ligature,  which 
was  left  long  intentionally  for  that  purpose,  the  raw  end  of  the  stump 
is  touched  with  pure  carbolic  acid  on  a  very  small  swab  or  else  it  is 
cauterized  with   a  pointed  Paquelin.      Some   aristol  may   then   be 


304  ABDOMEN  AND  BACK. 

rubbed  in,  the  ligature  cut  short,  and  the  stump  of  the  appendix 
allowed  to  drop  back  into  the  abdomen. 

2.    InVEBSION  OF  THE  STUMP  OF  THE  APPENDIX  WITHOUT  LlGA- 

titke. — After  the  mesentery  has  been  tied  off  and  cut  away  from  the 
appendix  and  without  applying  a  ligature  around  its  root,  the  ap- 
pendix is  seized  with  an  artery  clamp  and  amputated  within  one-half 
inch  of  its  junction  with  the  caecum.  The  short  stump  of  the  ap- 
pendix that  remains  is  then  inverted  into  the  lumen  of  the  caecum 
and  the  opening  into  the  caecum  corresponding  to  the  base  of  the 
inverted  appendix  stump  closed  with  a  row  of  fine  silk  Lembert  su- 
tures. There  is  no  bleeding  from  the  stump  of  the  appendix.  The 
amputation  of  the  appendix  may  be  done  with  the  scissors  or  the 


ILEUM 


Fig.  133.— Appendicectomy.    A  portion  of  the  wall  of  the  ceecum  removed  in  order 
to  show  the  inverted  appendix  stump  (A).    M,  meso-appendix  tied  off. 


Paquelin.     This  is  a  very  simple  and  satisfactory  way  of  treating 
the  appendix. 

3.  Inveesion  of  the  Stump  of  the  Appendix  with  Puese- 
steing  (Dawbaen). — After  the  mesentery  has  been  ligated  and  cut 
free  from  the  appendix,  the  latter  is  steadied  and  a  silk  purse-string 
suture  introduced  into  the  wall  of  the  caecum  so  as  to  surround  the 
root  of  the  appendix  at  a  distance  of  about  one-fourth  inch  all 
around.  This  stitch  should  include  only  the  serous  and  muscular 
coats  of  the  caecum;  it  should  not  penetrate  into  the  lumen  of  the 
bowel.  The  purse-string  suture  is  not  drawn  tight  or  tied,  but  the 
first  double  loop  of  a  surgeon's  knot  is  taken.  Then,  without  apply- 
ing any  ligature  around  its  root  the  appendix  is  seized  with  an  artery 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.  305 

forceps  and  cut  away  with  the  scissors,  leaving  a  stump  about  one- 
half  inch  long.  The  stump  does  not  bleed.  One  may  amputate  the 
appendix  with  a  Paquelin  instead  of  a  scissors. 

A  thin  artery  forceps  or  the  ends  of  a  thumb  forceps  are  next 
introduced  into  the  canal  of  the  stump  like  a  glove  stretcher,  and 
the  stump  is  stretched.  The  cut  end  of  the  stump  is  then  seized 
with  the  thumb  forceps  or  thin  artery  forceps  and  inverted  into 
the  caecum;  it  is  turned  "outside  in"  like  a  reversed  glove  finger. 
The  forceps  is  then  withdrawn,  and  at  the  same  time  the  purse- 
string  drawn  tight,  thus  leaving  the  inverted  stump  presenting  into 
the  caecum  and  closing  the  opening  in  the  caecum.  If  thought  nec- 
essary, one  may  still  further  secure  the  opening  in  the  caecum  by 
applying  two  or  three  Lembert  stitches  in  addition  to  the  purse- 
string.  This  is  a  very  satisfactory  method  of  dealing  with  the  stump 
of  the  appendix. 

4.  Inversion  of  the  Appendix  (Edebohls). — This  procedure 
is  applicable  to  cases  of  catarrhal  appendicitis  that  do  not  demand 
amputation  of  the  organ.  It  may  also  be  practiced  incidentally  dur- 
ing the  course  of  other  operations  in  order  to  preclude  the  possibility 
of  the  appendix  becoming  a  source  of  trouble  at  some  future  time. 
The  meso-appendix  is  first  tied  off  close  to  the  root  of  the  appendix 
and  then  cut  away  from  the  appendix  for  its  whole  length.  The 
point  of  a  probe  is  then  applied  to  the  tip  of  the  appendix,  and  with 
this  the  appendix  is  turned  "outside  in"  into  the  lumen  of  the  caecum 
as  one  would  reverse  the  finger  of  a  glove.  After  the  appendix  has 
been  inverted  into  the  caecum  and  while  it  is  thus  held  by  the  probe 
one  or  two  stitches  of  silk  are  taken  so  as  to  close  the  orifice  that 
corresponds  to  the  root  of  the  turned-in  appendix.  The  probe  is 
then  withdrawn  and  if  necessary  another  stitch  may  be  taken. 

These  stitches  that  unite  the  margins  of  the  orifice  that  corre- 
sponds to  the  root  of  the  appendix  serve  to  retain  the  appendix  in 
its  new  inverted  condition;  they  are  usually  of  silk  and,  of  course, 
are  non-penetrating. 

In  connection  with  any  of  these  methods  the  stump  of  the 
mesentery  may,  in  addition,  be  sutured  over -the  site  of  the  inverted 
appendix  stump. 

During  any  of  these  manipulations  it  is  necessary  for  an  assist- 
ant to  steady  the  caecum,  grasping  it  between  the  fingers  with  a  gauze 
pad,  which  gives  a  better  hold  and  at  the  same  time  protects  it  from 
becoming  soiled. 


306  ABDOMEN  AND  BACK. 

The  incision  in  the  abdomen  is  finally  closed,  as  indicated  above, 
without  drainage.  Proper  apposition  and  primary  healing  of  the 
incision  are  necessary  to  secure  the  patient  from  the  liability  to  sub- 
sequent ventral  hernia. 

Operations  for  Appendicular  Abscess. — Cases  that  go  on  to  sup- 
puration, resulting  in  the  formation  of  a  localized  intraperitoneal 
abscess  which  is  shut  off  from  the  general  peritoneal  cavity  by  adhe- 
sions between  immediately  adjacent  peritoneal  surfaces. 

The  abscess  is  opened  and  drained,  the  appendix  being  removed 
at  the  same  time  or  left,  according  to  the  circumstance  of  each  in- 
dividual case. 

During  the  opening  of  the  abscess  and  the  removal  of  the  ap- 
pendix care  should  be  exercised  not  to  break  through  the  barrier 
of  adhesions,  which  are  the  result  of  nature's  effort  to  protect  the 
general  peritoneal  cavity  from  infection. 

The  location  of  the  abscess  differs  in  different  cases:  it  may  be 
located  anterior  to  the  caecum  within  a  mass  of  matted  guts  and  may 
be  opened  as  soon  as  the  incision  in  the  abdominal  wall  is  carried 
through  the  parietal  peritoneum.  The  abscess  may  be  located  be- 
hind and  to  the  outer  or  right  side  of  the  caecum,  reaching  upward 
toward  the  kidney  and  liver  or  downward  into  the  pelvis,  or  it  may 
be  located  to  the  inner  or  left  side  of  the  caecum,  or  it  may  lie  almost 
entirely  within  the  pelvis  and  cause  symptoms  of  pressure  upon  the 
bladder.  Occasionally  there  is  more  than  one  collection,  and  care 
should  be  exercised  that  such  a  condition  does'  not  escape  our  atten- 
tion at  the  time  of  the  operation. 

The  Incision.  —  The  simple  incision  described  above,  cutting 
through  the  various  layers,  is  usually  employed.  It  should  be,  as  a 
rule,  about  four  inches  long,  and  may  be  increased  if  necessary  to 
allow  proper  work.  The  position  of  the  incision  may  be  somewhat 
changed  from  that  described  above  in  order  to  better  expose  the  tu- 
mor; thus  it  may  be  placed  farther  away  from  the  iliac  spine — nearer 
the  middle  line,  or  lower  down,  nearer  Poupart's  ligament  if  the 
position  of  the  tumor  should  indicate. 

Some  surgeons  use  McBurney's  gridiron  incision  for  abscess 
cases  as  well  as  for  the  simple  appendicectomies. 

The  incision  is  carried  through  the  abdominal  wall,  layer  by 
layer,  until  the  peritoneum  is  reached,  and  then  after  the  hemor- 
rhage has  been  controlled  the  peritoneum  is  incised  carefully  in  order 
to  avoid  wounding  the  underlying  gut,  which  may  be  adherent  to  the 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.      307 

parietal  peritoneum.  This  is  best  done  by  seizing  the  peritoneum 
with  two  mouse-tooth  forceps  and  cutting  between  them. 

Having  incised  the  parietal  peritoneum,  we  may  find  ourselves 
at  once  within  the  abscess  cavity.  In  such  cases  the  abscess  is  found 
to  be  located  in  front  of  the  caecum.  When  this  condition  exists, 
we  may  often  note,  in  making  the  incision  through  the  abdominal 
wall,  that  the  deeper  layers — subperitoneal  tissue,  etc. — are  cedem- 
atous  and  infiltrated. 

In  most  cases,  however,  after  the  parietal  peritoneum  has  been 
incised,  we  come  down  upon  a  mass,  consisting  of  the  caecum  and 
small  intestine  adherent  and  matted  together,  and  within  this  the 
appendix  and  abscess  are  inclosed.  This  mass  may  be  still  further 
adherent  to  the  overlying  parietal  peritoneum,  which  lines  the  poste- 
rior surface  of  the  anterior  abdominal  wall,  in  which  case  the  general 
peritoneal  cavity  is  excluded  from  the  likelihood  of  infection  from 
the  field  of  operation;  on  the  other  hand,  this  adhesion  between  the 
mass  of  matted  intestine  and  the  immediately  adjoining  parietal 
peritoneum  may  be  absent;  so  that,  when  the  fingers  are  introduced 
into  the  abdominal  cavity  through  the  incision,  they  may  be  passed 
freely  in  all  directions,  between  the  matted  mass  and  the  overlying 
parietal  peritoneum:  inward  toward  the  umbilicus,  upward  toward 
the  liver,  and  downward  into  the  pelvis. 

Having  exposed  the  mass  within  which  the  abscess  and  appendix 
are  inclosed,  we  are  ready  to  evacuate  the  abscess.  Before  doing 
this,  however,  the  parts  should  be  properly  protected  by  gauze  pads 
placed  around  and  into  the  incision  in  the  abdomen,  and,  if  the  con- 
dition exists  as  described  above, — i.e.,  if  no  adhesions  have  been 
formed  between  the  mass  of  intestine  which  incloses  the  appendix, 
etc.,  and  the  parietal  peritoneum, — the  pads  should  also  be  tucked 
into  this  space  (between  the  matted  mass  and  the  anterior  abdominal 
wall),  in  order  to  block  it,  off,  so  that  when  the  abscess  is  opened  the 
entrance  of  pus  into  the  general  peritoneal  cavity  will  be  prevented. 
Later,  after  the  abscess  has  been  evacuated,  etc.,  these  pads  may  be 
removed  and  replaced  by  fresh  sterile  pads  or  strips  of  gauze,  which 
are  allowed  to  remain,  with  their  ends  protruding  from  the  wound, 
in  order  to  obstruct  this  space  and  to  promote  the  formation  of  pro- 
tecting adhesions. 

The  abdominal  incision  is  held  open  with  retractors  and  search 
made  for  the  abscess.  The  appendix  is  not  to  be  seen,  being  adherent 
and  buried  within  the  mass  of  matted  guts.    We  can  locate  the  point 


308  ABDOMEN  AND  BACK. 

where  the  appendix  comes  off  from  the  csecum  by  following  down 
along  the  course  of  the  longitudinal  striae  and  gently,  with  the 
fingers,  working  between  the  adhesions  until  the  abscess  is  reached. 

As  the  abscess  is  opened  the  patient  may  be  turned  on  the  right 
side  to  facilitate  the  escape  of  the  pus,  which  is  swabbed  away  as  fast 
as  it  escapes.  The  abscess  cavity  may  be  gently  flushed  with  peroxide 
of  hydrogen,  which  may  be  preceded  and  followed  by  irrigation  with 
saline  solution. 

If  the  suppurative  process  involves  the  connective  tissue  behind 
the  colon,  reaching  up  toward  the  kidney,  a  counter-opening  may 
occasionally,  with  advantage,  be  made  in  the  loin. 

After  the  pus  has  been  evacuated  and  the  abscess  cavity  steril- 
ized we  may  attempt  the  removal  of  the  appendix.  Too  much  force, 
however,  especially  in  the  hands  of  inexperienced  operators,  should 
not  be  used  in  this  effort,  and  one  may  wisely  in  many  cases  ter- 
minate the  operation  at  this  stage,  being  content  with  packing  the 
abscess  cavity  and  leaving  the  appendix  to  take  care  of  itself,  or  to 
be  removed  later  after  suppuration  has  ceased,  thus  giving  the  patient 
the  best  chance  for  relief  from  immediate  danger. 

There  is  no  question  as  to  the  desirability  of  removing  the  ap- 
pendix at  the  time  that  the  abscess  is  opened  if  the  conditions  permit, 
and  one  should  make  an  effort  to  accomplish  this. 

If  the  appendix  lies  to  the  inner  side  of  the  csecum,  there  is 
probably  more  danger  in  attempting  to  remove  it  than  if  it  is  located 
to  the  outer  side  or  below.  The  manipulations  required  to  remove 
the  appendix  where  an  abscess  has  been  present  may  cause  a  break- 
ing through  of  the  adhesions  and  may  be  followed  by  peritonitis, 
under  which  circumstances  the  patient's  chance  of  recovery  is  greatly 
diminished.  On  the  other  hand,  to  leave  the  diseased  appendix  in 
the  wound  subjects  the  patient  to  the  liability  of  a  fsecal  fistula,  and 
— of  more  consequence  than  this — to  a  subsequent  attack  of  appen- 
dicitis, which  may  be  fatal. 

At  times,  after  the  pus  has  been  evacuated,  the  appendix  is 
fairly  accessible,  and  may  be  felt  or  seen  in  the  abscess  cavity;  so 
that,  by  farther  separating  the  adhesions  with  the  fingers  and  with 
the  introduction  of  deep  retractors,  it  may  be  reached  and  removed. 
It  usually  suffices  to  simply  tie  a  catgut  ligature  around  the  appendix 
close  to  its  root — say,  one-half  inch  distant  from  the  csecum — and 
amputate  it  with  the  scissors.  The  stump,  which  is  steadied  by  the 
ligature,  left  long  for  this  purpose,  may  then  be  sterilized  with  pure 


OPERATIONS  UPON  THE  VERMIFORM  APPENDIX.  309 

carbolic  acid  or  the  Paquelin.  If  conditions  permit,  instead  of 
treating  the  'stump  in  this  simple  manner  it  may  be  inverted  into 
the  cascum,  as  described  above. 

For  drainage  the  most  satisfactory  material  is  iodoform  gauze, 
which  may  be  loosely  packed  in  the  abscess  cavity  or  else  made  into 
separate  bundles  inclosed  in  perforated  casings  of  oil-silk  or  gutta- 
percha tissue;  in  addition  to  the  iodoform  gauze  it  is  often  advisable 
to  use  one  or  more  glass  or  rubber  tubes  perforated  on  the  sides, 
especially  if  the  abscess  cavity  reaches  down  into  the  pelvis.  Some 
surgeons  use  lamp-wick  instead  of  the  gauze  for  drainage. 

The  wound  in  the  abdomen  should  be  closed  in  part  with  two  or 
three  silk-worm  sutures  which  include  all  the  layers,  especially  the 
parietal  peritoneum,  and  which  are  introduced  with  a  large  curved 
surgeon's  needle.  Several  similar  sutures  may  also  be  introduced 
through  the  edges  of  that  part  of  the  wound  which  is  to  be  left  open, 
but  these  are  left  untied  until  after  the  suppuration  has  ceased  and 
the  drains  have  been  removed. 

Operations  for  Appendicitis  Accompanied  by  Progressive  or  Gen- 
eral Peritonitis  or  Peritoneal  Infection  due  to  perforation  or  slough- 
ing of  the  appendix  before  adhesions  have  been  formed  or  to  rupture 
or  leakage  of  an  appendicular  abscess  after  adhesions  have  been 
formed.  In  these  cases  the  appendix  should  be  removed  and  an  at- 
tempt made  to  prevent  or  check  the  general  peritoneal  infection. 

The  incision  should  be  sufficiently  long — four  to  six  inches;  if 
a  tumor  has  existed  in  the  right  iliac  region  it  is  probably  best  to 
place  the  incision  in  the  right  semilunar  line,  reaching  down  to  Pou- 
part's  ligament.  The  incision  in  other  cases  may  be  better  placed 
in  the  middle  line  of  the  abdomen  between  the  umbilicus  and  the 
symphysis  pubis,  especially  if  previously  there  has  been  no  tumor  in 
the  right  iliac  fossa  and  the  onset  has  been  sudden  or  in  cases  where 
the  diagnosis  is  somewhat  in  doubt  and  signs  of  a  general  peritonitis 
are  present. 

After  the  abdomen  has  been  opened  the  appendix  is  at  once 
sought  and  removed.  The  fluids  in  the  immediate  neighborhood  of 
the  appendix  are  sponged  away,  and  the  whole  abdominal  cavity  and 
intestine  thoroughly  flushed  with  normal  salt  solution.  The  pelvis, 
where  fluids  are  especially  apt  to  collect,  should  be  cleared  and 
flushed.  This  flushing  should  be  thorough,  using  quarts  of  water 
poured  from  a  pitcher  or  thrown  into  the  abdomen  through  a  thick 
glass  tube.     This  washing  should  be  clone,  if  possible,  without  re- 


310  ABDOMEN  AND  BACK. 

moving  the  intestines  from  the  abdominal  cavity,  as  this  adds  greatly 
to  the  shock,  and  there  may  be  some  difficulty  in  replacing  them. 
One  may  follow  the  saline  irrigation  with  peroxide  of  hydrogen,  this 
in  turn  being  followed  up  by  a  final  washing  with  saline  solution. 

If  the  intestine  is  coated  with  flaky  exudate  and  matted  with 
fresh  adhesions,  it  may  be  advisable  to  break  these  up  with  the 
fingers  in  order  to  make  the  flushing  satisfactory  and  thorough. 

A  glass  or  rubber  drainage  tube  with  a  gauze  strip  passed 
through  it  may  be  introduced  into  the  abdomen,  reaching  well  down 
into  the  pelvis,  and  strips  of  iodoform  gauze  and  drainage  tubes  may 
be  introduced  into  the  abdomen  down  into  the  region  of  the  ap- 
pendix, and  in  other  directions  also.  The  incision  in  the  abdomen 
is  closed  in  part  with  interrupted  sutures  of  silk-worm  gut  which 
pass  through  all  the  layers  of  the  abdominal  wall,  including  the 
parietal  peritoneum. 

THE  LIVER  AND  GALL=BLADDER. 

The  Surgical  Anatomy  of  the  Liver. — The  liver  is  a  solid  gland- 
ular organ  almost  completely  invested  by  the  peritoneum,  suspended 
in  the  upper  right  portion  of  the  abdomen  (right  hypochondrium) 
and  extending  beyond  the  middle  line  into  the  left  side  (left  hypo- 
chondrium). It  is  situated  under  cover  of  and  protected  by  the  ribs, 
except  in  the  epigastric  region.  Behind  and  toward  the  right  the 
liver  is  thick,  gradually  becoming  thin  toward  the  front  and  left. 
From  side  to  side  it  measures  eleven  inches;  from  before  backward, 
eight  inches;  and  its  posterior  border  has  a  thickness  of  two  and 
one-half  inches. 

Above,  the  diaphragm  separates  the  liver  from  the  pleura  and 
pericardium;  below  it  are  the  gall-bladder,  hepatic  flexure  of  the 
colon,  the  first  part  of  the  duodenum,  the  pylorus  and  stomach 
(which  it  overlaps),  and  the  right  kidney  and  suprarenal  capsule. 

The  siiperior  surface  of  the  liver  looks  forward  as  well  as  up- 
ward, and  is  in  relation  with  the  diaphragm  and  with  the  ribs  and 
costal  cartilages  from  the  fifth  or  sixth  to  the  tenth.  The  lower 
limit  of  this  surface  corresponds  to  the  free  border  of  the  ribs  (costal 
cartilages).  This  upper  surface  of  the  liver  is  smooth,  and  presents 
a  fold  of  peritoneum  running  from  the  anterior  border  backward, 
the  suspensory  ligament.  This  serves  to  suspend  the  liver  to  the 
diaphragm,  and  is  the  continuation  of  the  falciform  fold  of  perito- 
neum, which  is  thrown  around  the  round  ligament  from  the  anterior 


SURGICAL  ANATOMY  OF  THE  LIVER.  311 

abdominal  wall  and  which  extends  from  the  umbilicus  to  the  anterior 
edge  of  the  liver.  The  suspensory  ligament  divides  the  upper  sur- 
face of  the  liver  into  the  larger  right  lobe  and  the  smaller  left  lobe; 
the  latter  overlaps  the  stomach  and  reaches  to  the  left  beyond  the 
middle  line.  Toward  the  posterior  border  of  the  liver  the  folds  of 
the  suspensory  ligament  spread  out  right  and  left,  and,  still  passing 
between  the  liver  and  the  diaphragm,  form  the  anterior  layer  of  the 
coronary  ligament. 

The  posterior  border  of  the  liver,  really  a  surface,  is  thick, 
gradually  becoming  thin  toward  the  left,  and  is  not  covered  by 
peritoneum;  the  peritoneum  which  covers  the  upper  surface  of  the 
liver  upon  reaching  its  posterior  border  is  reflected  upward  to  the 
diaphragm  as  the  anterior  layer  of  the  coronary  ligament,  and  that 
which  covers  the  under  surface  upon  reaching  the  posterior  border 
of  the  liver  is  reflected  on  to  the  posterior  abdominal  wall  (dia- 
phragm), forming  the  posterior  layer  of  the  coronary  ligament.  The 
coronary  ligament,  at  either  end,  forms  the  right  and  left  lateral 
ligaments  of  the  liver.  The  posterior  border  of  the  liver,  to  the  left 
of  the  middle  line,  presents  a  notch  which  corresponds  to  the  oesoph- 
agus and  which  marks  the  division  of  the  liver  into  its  right  and  left 
lobes.  The  posterior  border  of  the  liver  is  in  relation  with  the  dia- 
phragm and  lower  ribs,  with  the  vertebral  column,  tenth  and  elev- 
enth dorsal,  the  aorta,  vena  cava  inferior,  etc.  The  oesophagus  is 
received  in  the  notch  above  mentioned. 

The  anterior  border  is  thin,  reaches  just  below  the  free  border 
of  the  ribs  (costal  cartilages),  and  corresponds  to  a  line  drawn  from 
the  tip  of  the  right  tenth  to  the  tip  of  the  left  eighth  costal  carti- 
lage, where  this  joins  the  cartilage  of  the  seventh. 

The  under  surface  of  the  liver  is  irregular  and  marked  by 
grooves  and  impressions  for  the  colon,  gall-bladder,  kidney,  etc.,  and 
is  covered  by  the  peritoneum,  which  is  reflected  downward  at  the 
transverse  fissure,  as  the  lesser  omentum,  as  far  as  the  lesser  curva- 
ture of  the  stomach,  where  its  folds  separate  to  include  the  stomach 
between  them. 

Besides  the  right  and  left  lobes,  the  under  surface  of  the  liver 
presents  three  smaller  lobes:  the  quadrate,  caudate,  and  the  lobus 
Spigelii.  The  large  right  lobe  is  marked  by  the  transverse  fissure, 
which  passes  from  right  to  left  and  is  situated  rather  more  than 
half-way  back  from  the  anterior  border. 

At  this  fissure,  the  vessels,  ducts,  lymphatics,  and  nerves  pass 


312  ABDOMEN  AND  BACK. 

in  and  out  of  the  liver.  These  structures  descend  in  the  right  free 
horder  of  the  lesser  omentum,  between  its  two  folds,  the  common 
bile-duct  to  the  right,  the  hepatic  artery  to  the  left,  and  the  portal 
vein  between  and  behind  these  two.  The  hepatic  duct,  which  is 
formed  by  the  junction  of  the  right  and  left  bile-ducts,  emerges  from 
the  right  end  of  the  transverse  fissure  and  descends  between  the 
folds  of  the  lesser  omentum,  where  it  is  joined  by  the  cystic  duct 
to  form  the  common  bile-duct,  ductus  choledochus. 

If  we  examine  the  under  surface  of  the  liver  as  this  organ  lies 
in  its  normal  position  in  the  abdomen,  through  a  vertical  incision 
made  in  the  abdomen  from  the  tip  of  the  ninth  costal  cartilage,  we 
note,  in  sweeping  across  the  surface  from  right  to  left,  two  well- 
marked  grooves,  or  depressions,  into  which  the  finger  sinks;  the 
first,  that  toward  the  right,  corresponding  to  the  tip  of  the  ninth 
costal  cartilage,  lodges  the  gall-bladder;  the  second,  nearer  the 
middle  line,  corresponds  to  the  round  ligament  (foetal  umbilical 
vein). 

The  Surgical  Anatomy  of  the  Gall-bladder. — The  gall-bladder  is 
a  pear-shaped,  hollow  receptacle.  Its  wall  is  fairly  thick  and  is  com- 
posed of  muscle  and  mucous  membrane.  The  serous,  coat  (perito- 
neum) invests  the  under  surface  of  the  body  and  all  of  the  fundus 
of  this  organ,  binding  it  to  the  under  surface  of  the  liver.  The  gall- 
bladder lies  in  direct  relation  with  the  under  surface  of  the  liver, 
in  the  fossa  of  the  gall-bladder,  the  apposed  surfaces  of  the  gall- 
bladder and  liver  being  joined  to  each  other  by  loose  connective 
tissue. 

The  fundus  of  the  gall-bladder  is  directed  downward,  forward, 
and  to  the  right,  usually  appearing  below  the  anterior  thin  edge  of 
the  liver,  opposite  the  tip  of  the  ninth  costal  cartilage.  Sometimes 
it  does  not  reach  quite  as  far  as  the  anterior  edge  of  the  liver,  and 
is  then  concealed  underneath  the  liver.  The  edge  of  the  liver,  corre- 
sponding to  the  fundus  of  the  gall-bladder,  is  sometimes  marked  by 
a  slight  notch. 

The  gall-bladder  is  three  to  four  inches  long  and  has  a  capacity 
of  about  one  and  one-half  ounces.  The  fundus  rests  upon  the  trans- 
verse colon,  and  the  neck,  the  posterior  narrow  part,  upon  the  first 
part  of  the  duodenum.  To  the  outer  side  of  the  gall-bladder — i.e., 
to  the  right — is  the  hepatic  flexure  of  the  colon;  to  the  left  is  the 
pyloric  end  of  the  stomach.  The  neck  of  the  gall-bladder  is  con- 
tinned  into  the  cystic  duct.     The  cystic  duct  is  about  one-twelfth 


SURGICAL  ANATOMY  OF  THE  GALL-BLADDER.  313 

inch  in  diameter  and  one  to  two  inches  long.  Its  interior  has  an 
irregular,  spiral,  twisted  shape,  which  makes  difficult  the  passage  of 
a  sound  through  it.  It  curves  down  hehind  the  first  part  of  the  duo- 
denum, and  joins  with  the  hepatic  duct  between  the  folds  of  the 
lesser  omentum  to  form  the  common  bile-duct. 

The  hepatic  duct  is  one-sixth  inch  in  diameter  and  two  inches 
long;  it  is  formed  by  the  junction  of  the  bile-ducts  from  the  right 
and  left  lobes  of  the  liver. 

The  common  bile-duct,   ductus  communis   choledochus,  varies 


Fig.  134.— Bile-ducts,  etc.     C,  cystic  duct;  CB,  common  duct;  OB, 
gall-bladder;  H,   hepatic  ducts;  P,   pancreatic  duct. 

in  length:  it  is  usually  three  inches  long  and  one-fourth  inch  in 
diameter;  it  continues  the  course  of  the  hepatic  duct,  descending 
between  the  folds  of  the  lesser  omentum,  lying  near  its  right  free 
edge.  In  this  situation  it  lies  in  front  of  the  portal  vein  with  the 
hepatic  artery  on  its  left  side;  continuing  downward  it  passes  behind 
the  first  part  of  the  duodenum,  and  finally  behind  and  to  the  inner 
side  of  the  second  part  of  duodenum,  between  it  and  the  head  of  the 
pancreas,  where  it  meets  the  pancreatic  duct;  these  unite  and  perfo- 
rate the  wall  of  the  duodenum  (second  part)  upon  its  inner,  poste- 
rior aspect,  running  very  obliquely  in  the  wall  of  this  part  of  the 


314  ABDOMEN  AND  BACK. 

gut  for  one-half  to  three-fourths  inch;  the  opening  of  the  duct  upon 
the  inner  surface  of  the  gut  is  marked  by  a  papilla.  This  papilla  is 
distant  about  four  inches  from  the  pylorus. 


OPERATIONS  UPON  THE  LIVER. 

Hepatotomy. — Incision  of  the  liver  for  abscess,  hydatid  cyst,  etc. 

The  incision,  when  the  disease  involves  the  right  lobe,  is  placed 
along  the  outer  border  of  the  rectus  muscle,  extending  from  the  tip 
of  the  ninth  costal  cartilage  downward  for  a  distance  of  from  three 
to  five  inches. 

At  times  it  may  be  desirable  to  place  the  incision  elsewhere  in 
order  that  it  may  correspond  with  the  prominence  of  the  tumor; 
for  example,  if  the  abscess  is  located  in  the  left  lobe  of  the  liver, 
then  the  incision  is  better  placed  in  the  middle  line,  linea  alba.  The 
incision  is  carried  through  the  integument,  fascia,  etc.,  down  to  the 
peritoneum,  and  after  the  hemorrhage  has  been  controlled  the 
parietal  peritoneum  is  incised  between  two  mouse-tooth  forceps.  We 
may  find  the  tumor  adherent  to  the  parietal  peritoneum,  and  in  this 
case,  after  aspirating  to  discover  the  nature  of  its  contents,  we  may 
incise  the  tumor  and  evacuate.  The  finger  is  then  introduced  into 
the  abscess  cavity  to  explore  and  break  up  septa,  etc.  The  cavity  is 
finally  packed  with  iodoform  gauze.  Under  these  circumstances  the 
operation  is  very  simple  and  there  is  no  danger  whatever  of  infecting 
the  general  peritoneal  cavity. 

If,  however,  after  incising  the  peritoneum  we  find  that  the  tu- 
mor is  not  adherent  to  the  parietal  peritoneum, — i.e.,  if  we  can  pass 
the  hand  freely  between  the  tumor  and  the  parietal  peritoneum, — 
we  must  take  measures  to  prevent  infection  of  the  general  peritoneal 
cavity  while  the  contents  of  the  cavity  are  being  evacuated,  and  to 
accomplish  this  we  do  the  operation  in  two  sittings. 

First,  having  exposed  the  tumor,  the  parietal  peritoneum  is 
united  to  the  edges  of  the  skin  with  two  or  three  catgut  sutures  on 
either  side,  and  then  strips  of  gauze  are  packed  into  the  wound  be- 
tween the  tumor  and  parietal  peritoneum  for  the  purpose  of  shutting 
off  the  general  peritoneal  cavity  in  case  of  leakage  and  to  stimulate 
the  formation  of  adhesions  between  the  tumor  and  the  parietal  peri- 
toneum. One  may  then  aspirate  with  a  fine  needle  in  order  to  discover 
the  nature  of  the  contents  and  to  relieve  the  tension  somewhat. 

The  incision  in  the  abdomen  is  left  open  and  packed  down  to 


OPERATIONS  UPON  THE  GALL-BLADDER.  3 15 

the  surface  of  the  tumor  or  the  incision  may  be  closed  in  part  by 
one  or  two"  sutures  of  silk-worm  gut  which  pass  through  all  the 
layers  of  the  abdomen,  including  the  parietal  peritoneum. 

After  an  interval  of  several  days,  when  adhesions  have  formed, 
etc.,  the  tumor,  abscess,  or  hydatid  cyst  may  be  incised  either  with 
the  Paquelin  cautery  or  the  knife,  and  drained. 

Hepatectomy  (Excision  of  Diseased  Portion  of  the  Liver). — Por- 
tions of  the  liver  have,  in  a  few  instances,  been  excised  when  involved 
primarily  or  by  extension  from  growths  of  the  gall-bladder  and  ducts 
either  by  means  of  the  Paquelin  cautery  or  by  blunt  dissection 
(enucleation)  with  the  finger.  Large  individual  vessels  may  be 
clamped  and  tied  as  they  are  met  with  during  the  operation.  The 
space  which  remains  in  the  liver  after  the  removal  of  the  diseased 
part  may  be  closed  by  approximation  of  its  edges  with  sutures  of 
catgut;   but  if  there  is  much  tension  these  may  tear  through. 

Injuries  of  the  Liver. — The  liver  may  be  lacerated  by  blows 
upon  the  abdomen,  by  fractured  ribs,  or  by  bodies  causing  penetrat- 
ing wounds.  These  injuries  may  be  accompanied  by  free  hemorrhage. 
On  account  of  the  solid  structure  of  the  liver  large  venous  channels 
cannot  collapse,  and  thus  hemorrhage  is  favored.  Hemorrhage  may 
be  controlled  by  the  cautery  or  by  packing,  or  by  packing  combined 
with  suture. 

OPERATIONS  UPON  THE  GALL=BLADDER. 

Aspiration  of  the  Gall-bladder. — Drawing  off  the  contents  of  the 
gall-bladder,  usually  for  purposes  of  diagnosis. 

Aspiration  may  be  resorted  to  in  order  to  determine  the  nature 
of  a  tumor  which  can  be  felt  through  the  abdominal  wall. 

The  needle  is  introduced  over  the  most  prominent  part  of  the 
tumor,  usually  below  the  tip  of  the  ninth  costal  cartilage,  and  some 
of  the  contents  withdrawn.     The  needle  should  be  of  small  caliber. 

This  is  a  dangerous  procedure  and  one  to  be  condemned,  even 
if  the  needle  and  skin  are  made  aseptic,  because  some  of  the  contents 
is  very  apt  to  escape  through  the  puncture  in  the  wall  of  the  gall- 
bladder upon  withdrawing  the  needle,  especially  if  the  needle  used 
is  not  fine,  and  if  the  material  is  infectious  a  fatal  peritonitis  may 
be  thus  set  up. 

Cholecystotomy. — Opening  the  gall-bladder  for  the  purpose  of 
removing  stones,  etc. 

An  incision  is  made  which  reaches  from  the  tip  of  the  ninth 


316  ABDOMEN  AND  BACK. 

costal  cartilage  vertically  downward,  in  the  linea  semilunaris,  along 
the  outer  side  of  the  rectus  or  just  exposing  the  outer  edge  of  this 
muscle,  three  to  four  inches  long.  Having  cut  through  the  several 
layers  of  the  wall  of  the  abdomen,  the  parietal  peritoneum  is  ex- 
posed. Before  incising  the  peritoneum,  all  bleeding  points  in  the 
abdominal  wall  are  clamped.  The  parietal  peritoneum  is  then 
caught  up  with  two  mouse-tooth  forceps  and  snipped  between  these 
with  the  knife,  whereupon  the  finger  is  introduced  and  the  opening 
enlarged  with  the  scissors,  cutting  upon  the  finger  as  a  guide. 

Instead  of  the  vertical  incision  one  may  make  an  oblique  in- 
cision, one  finger's  breadth  distant  from  and  parallel  with  the  free 
border  of  the  ribs,  the  middle  of  the  incision  corresponding  to  the 
tip  of  the  ninth  costal  cartilage.  This  incision  is  usually  four  to 
five  inches  long.  The  vertical  incision  is  probably  the  preferable 
one.  After  the  parietal  peritoneum  has  been  incised  the  sharp  ante- 
rior edge  of  the  liver  is  exposed  in  the  upper  part  of  the  incision  and 
the  transverse  colon  in  the  lower  part  of  the  incision.  The  gall- 
bladder may  be  seen  more  or  less  distended,  projecting  beneath  the 
anterior  border  of  the  liver,  or  it  may  be  small  and  concealed  beneath 
the  edge  of  the  liver. 

Occasionally  in  order  to  bring  the  fundus  of  the  gall-bladder 
into  the  wound  it  may  be  necessary  to  draw  the  liver  well  upward  or 
to  incise  the  thin  layer  of  liver-tissue  that  overlies  the  fundus  of 
the  gall-bladder,  or  it  may  be  necessary,  with  the  finger,  to  break 
up  some  adhesions  that  bind  down  the  gall-bladder. 

In  the  cadaver  some  difficulty  may  be  experienced  in  locating 
the  gall-bladder  and  bringing  it  up  into  the  wound,  as  the  liver,  post- 
mortem, sinks  backward  and  away  from  the  anterior  abdominal  wall 
and  upward  into  the  thorax,  carrying  the  gall-bladder  with  it.  The 
gall-bladder  is  sought  in  the  fossa  of  the  gall-bladder  upon  the  under 
surface  of  the  liver,  its  fundus  corresponding  to  the  tip  of  the  ninth 
costal  cartilage. 

When  the  fundus  of  the  gall-bladder  has  been  located,  two  silk 
tractors  may  be  introduced  into  its  wall  to  steady  it;  these  should 
take  a  good,  firm,  broad  bite,  but  should  not  penetrate  through  the 
entire  thickness  of  its  wall.  Gauze  pads  are  then  tucked  into  the 
incision  and  around  the  gall-bladder  in  order  to  shut  it  off  from  the 
peritoneal  cavity. 

If  the  gall-bladder  is  much  distended,  one  may  aspirate  to  dis- 
cover the  nature  of  the  contents  and  to  diminish  the  tension  and 


OPERATIONS  UPON  THE  GALL-BLADDER.  317 

size  of  the  tumor,  and  then,  making  an  incision  in  its  fundus,  it  is 
emptied  of  its  contents,  any  remaining  fluid  being  withdrawn  with 
sponges  on  a  stick,  and  the  finger  introduced  for  exploration.  If 
any  stones  are  present,  these  may  be  removed  with  a  scoop  or  forceps. 
With  the  hand  in  the  abdominal  cavity  one  should  thoroughly  pal- 
pate the  cystic,  hepatic,  and  common  bile-ducts.  Stones  impacted  in 
the  cystic  duct  may  be  forced  back  into  the  gall-bladder  and  removed. 

Having  emptied  the  gall-bladder  and  convinced  one's  self  that 
the  ducts  are  patent  and  if  the  contents  of  the  gall-bladder  were  not 
purulent,  one  may  proceed  at  once  to  close  the  opening  in  the  gall- 
bladder and  the  incision  in  the  abdomen. 

To  test  the  patency  of  the  ducts  one  may  introduce  a  gum 
catheter  through  the  incision  in  the  gall-bladder  into  the  cystic  duct 
and  onward  through  this  into  the  common  duct.  Owing  to  the 
twisting  and  irregularity  of  the  interior  of  the  cystic  duct,  however, 
the  catheter  may  catch  in  its  wall  and  fail  to  pass  even  when  the 
duct  is  pervious.  If  not  successful  with  the  catheter,  Abbe  has 
suggested  a  stream  of  water  introduced  into  the  gall-bladder  under 
pressure;   if  it  flows  freely  it  indicates  the  patency  of  the  ducts. 

The  incision  in  the  gall-bladder  may  be  closed  with  a  double 
row  of  sutures.  The  first  row,  which  may  be  of  catgut,  includes  the 
whole  thickness  of  the  wall  and  serves  to  close  the  opening;  it  may 
be  continuous  or  consist  of  several  interrupted  stitches.  This  first 
line  of  suture  is  reinforced  by  a  second  row  of  Lembert  sutures, 
which  should  include  only  the  serous  and  muscular  coats  of  the  gall- 
bladder; these  serve  to  bury  the  first  row  and  bring  the  adjoining 
serous  surfaces  into  accurate  apposition.  Unless  one  is  certain  that  no 
obstruction  exists  in  the  bile-ducts,  it  is  advisable  to  allow  the  opening 
in  the  gall-bladder  to  remain;  i.e.,  to  sew  the  edges  of  the  incision  in 
the  gall-bladder  to  the  margins  of  the  abdominal  incision  (chole- 
cystostomy). 

If  "the  incision  in  the  abdomen  is  to  be  closed,  this  is  effected 
by  uniting,  first,  the  edges  of  the  parietal  peritoneum  with  a  con- 
tinuous catgut  suture.  The  transversalis  fascia  and  muscle  (aponeu- 
rosis) are  then  brought  together  with  a  second  continuous  catgut 
suture,  and  finally  the  edges  of  the  skin  are  united  by  a  catgut  suture. 
After  the  edges  of  the  peritoneum  have  been  sutured  we  may  ap- 
proximate the  other  layers — skin,  aponeurosis,  fascia,  etc. — with  sev- 
eral interrupted  sutures  of  silk-worm  gut,  each  suture  including  all 
of  these  layers,  but  omitting  the  peritoneum. 


318  ABDOMEN  AND  BACK. 

Cholecystostomy. — Formation  of  a  fistulous  opening  in  the  gall- 
bladder; for  the  removal  of  calculi  from  the  gall-bladder.  The  op- 
eration may  be  done  in  one  or  two  sittings. 

An  incision  as  described  in  the  preceding  operation,  either 
vertical,  passing  from  the  tip  of  the  ninth  costal  cartilage  downward, 
or  oblique,  parallel  with  the  free  border  of  the  ribs.  Probably  the 
vertical  incision  is  preferable  in  most  cases. 

The  incision  may  be  located  nearer  to  the  middle  line  if  the 
presence  of  a  tumor  indicates,  so  that  it  may  be  over  the  most  promi- 
nent part  of  the  tumor. 

Cholecystostomy  in  one  Sitting. — Having  opened  into  the 
abdomen,  the  gall-bladder  is  usually  found  distended  and  presenting 
beneath  the  free  anterior  edge  of  the  liver,  and  may  be  more  or  less 
adherent  to  neighboring  parts — colon,  duodenum,  etc.  These  adhe- 
sions may  be  gently  broken  down  by  the  fingers  in  the  abdomen  and 
the  cystic,  hepatic,  and  common  bile-ducts  palpated  for  an  impacted 
calculus,  etc. 

The  edge  of  the  parietal  peritoneum  is  fixed  to  the  margin  of 
the  skin  by  two  interrupted  catgut  sutures  on  either  side.  The 
gall-bladder  is  then  drawn  into  the  incision,  and,  after  pads  have 
been  arranged  so  as  to  protect  the  peritoneal  cavity,  two  silk  tractor 
sutures  are  introduced  into  its  fundus,  care  being  taken  to  avoid 
passing  entirely  through  the  wall  into  its  cavity.  While  the  bladder 
is  steadied  by  the  tractor  sutures  it  is  emptied  of  its  contents  as 
completely  as  possible  with  the  aspirator  or  a  trochar,  and  an  in- 
cision then  made  in  the  fundus  of  the  bladder  and  the  edges  of  the 
incision  seized  with  artery  forceps.  The  contents  of  the  gall-bladder 
should  be  entirely  evacuated,  any  remaining  fluid  being  sponged  out 
with  pads  upon  sticks,  and  stones  removed  with  a  scoop  or  forceps. 
A  stone  impacted  in  the  cystic  duct  may  be  pushed  back  into  the 
bladder  and  removed.  If  the  cystic  duct  has  been  obstructed,  as 
soon  as  the  obstruction  is  relieved  there  is  apt  to  be  a  copious  flow 
of  bile  from  the  cystic  duct  into  the  gall-bladder.  This  bile  should 
be  prevented  from  entering  the  peritoneal  cavity.  Although  bile  in 
the  peritoneal  cavity  does  not  cause  a  septic  peritonitis,  still  its  en- 
trance in  any  considerable  quantity  should  be  avoided. 

After  having  explored  the  interior  of  the  gall-bladder,  removed 
stones,  examined  the  ducts,  and  tested  their  patency,  we  are  ready 
to  sew  the  edges  of  the  opening  in  the  gall-bladder  to  the  edges  of 
the  incision  in  the  abdominal  wall.    This  is  done  with  a  number  of 


OPERATIONS  UPON  THE  GALL-BLADDER.  319 

interrupted  silk  sutures  placed  fairly  close  together,  the  ends  being 
left  long  to  facilitate  their  removal  later.  The  stitches  should  be 
about  one-fourth  inch  apart.  Care  should  be  taken  to  bring  the 
peritoneal  surface  of  the  gall-bladder  into  accurate  apposition  with 
the  parietal  peritoneum,  which  has  already  been  sutured  to  the  skin. 
That  part  of  the  abdominal  incision  which  is  to  be  closed  should  be 
brought  together  with  several  silk-worm  gut  sutures,  each  passing 
through  all  the  layers  and  including  especially  the  parietal  perito- 
neum. The  stitches,  above  and  below,  immediately  adjacent  to  the 
fixed  gall-bladder,  may  also  include  the  wall  of  the  gall-bladder  in 
their  course. 


Fig.  135. — A  Purse-string  Suture  has  been  Introduced  Around  the  in- 
cision in  the  Fundus  of  the  Gall-bladder  Close  to  its  Edge.  When  the  purse- 
string  is  drawn  tight  it  tends  to  invert  the  edges  of  the  opening  around  the 
tube,  and  thus  accelerates  its  closure. 

Finally  a  drainage  tube  is  introduced  into  the  opening  in  the 
gall-bladder  and  the  wound  loosely  packed  with  iodoform  gauze. 

McBumey  Modification.— -In  order  to  facilitate  the  rapid  oblit- 
eration of  the  resulting  fistula,  the  gall-bladder  may  be  united  to 
the  edge  of  the  abdominal  incision  by  a  row  of  sutures  which  do 
not  include  the  edge  of  the  incision  in  the  gall-bladder,  but  which 
catch  its  wall  without  passing  entirely  through  it,  just  external  to 
the  opening  all  around;  and  then,  before  the  drainage  tube  is  intro- 
duced, a  purse-string  suture  which  passes  through  the  whole  thick- 
ness of  the  wall  of  the  gall-bladder  is  introduced  around  and  close 
to  the  margin  of  the  opening  in  the  gall-bladder,  so  that  when  it  is 
drawn  tight  it  will  grasp  the  tube  and  at  the  same  time  invert  the 


320 


ABDOMEN  AND  BACK. 


edges  of  the  opening  in  the  gall-bladder  closely  around  it.  The 
wound  is  then  packed  and  dressed  in  the  usual  way.  After  the  tube 
is  withdrawn  the  opening  in  the  gall-bladder,  with  the  inverted 
edges,  tends  to  close  more  rapidly. 


Fig.  136.—  Cholecystectomy.  Fundus  of  the  gall-bladder  ((?)  drawn  Into 
the  incision  and  fixed;  A,  D,  sutures  through  all  the  layers  of  the  abdominal 
wall  that  serve  to  diminish  size  of  the  incision;  B,  C,  sutures  that  pass 
through  the  edges  of  the  incision  in  the  abdomen,  but  catch  up  the  wall  of 
the  gall-bladder  as  they  pass  across  from  one  edge  of  the  incision  to  the 
other;  E,  sutures  that  join  the  edges  of  the  peritoneum  to  the  skin. 

Cholecystostomy  in  two  Sittings. — This  method  is  especially 
applicable  if  the  contents  of  the  gall-bladder  are  purulent. 

Through  the  vertical  incision,  about  four  inches  long,  in  the  ab- 


OPERATIONS  UPON  THE  GALL-BLADDER.  321 

dominal  wall,  the  gall-bladder  is  exposed  and  the  bile-ducts,  etc.,  pal- 
pated. After  pads  have  been  arranged  so  as  to  protect  the  peritoneal 
cavity,  a  fine  aspirating  needle  may  be  thrust  into  the  bladder  and 
some  of  the  contents  drawn  off.  If  the  contents  are  purulent,  the 
operation  had  better  be  done  in  two  sittings. 

The  parietal  peritoneum  is  first  fixed  to  the  margins  of  the 
abdominal  incision  with  two  interrupted  catgut  sutures  {E,  Fig.  136) 
on  each  side;  these  join  the  edge  of  the  peritoneum  to  the  edge  of 
the  skin.  Two  tractor  sutures  which  do  not  penetrate  through  the 
entire  thickness  of  its  wall  are  then  introduced  into  the  fundus  of 
the  bladder  in  order  to  steady  it. 

Four  silk-worm  gut  sutures  (A,  B,  C,  D,  Fig.  136)  are  now  in- 
troduced through  the  edges  of  the  abdominal  incision:  two  in  the 
upper  part  of  the  incision  and  two  in  the  lower  part. 

Each  of  these  sutures  passes  through  all  the  layers  of  the  ab- 
domen; the  two  middle  sutures,  marked  B  and  C  (Fig.  136),  pick  up 
the  wall  of  the  gall-bladder  in  their  course,  but  do  not  pass  through  its 
entire  thickness.  They  serve  to  partially  fix  the  bladder  in  the  ab- 
dominal incision.  There  should  be  a  space  of  one  and  one-half  to  two 
inches  intervening  between  these  two  sutures. 

The  uppermost  and  lowermost  sutures,  marked  A  and  D,  which 
are  simply  for  the  purpose  of  closing  the  abdominal  incision  for  part 
of  its  length,  are  introduced  first,  but  they  are  not  tied  until  after 
those  which  pick  up  the  wall  of  the  gall-bladder  have  been  intro- 
duced. 

The  fundus  of  the  gall-bladder  is  then  still  further  united  to  the 
edges  of  that  part  of  the  abdominal  incision  which  is  to  be  left  open 
— i.e.,  between  the  sutures  B  and  C — with  several  additional  catgut 
or  silk  sutures  on  either  side.  These  do  not  pass  through  the  entire 
thickness  of  the  wall  of  the  gall-bladder,  and  are  best  introduced 
with  a  narrow,  curved  surgeon's  needle.  It  may  facilitate  the  intro- 
duction of  these  accessory  sutures  if  the  sutures  B  and  C  are  left 
untied  until  these  accessory  sutures  have  been  introduced.  As  a 
result,  we  have  the  abdominal  wound  left  open  for  one  and  one-half 
to  two  inches  of  its  length,  and  the  fundus  of  the  gall-bladder  fixed 
there. 

The  wound  is  then  packed,  leaving  the  tractor  sutures  in  place, 
and  after  two  to  five  days  the  gall-bladder  may  be  opened  between 
the  tractors  with  a  knife  or  Paquelin  cautery  and  emptied  of  its 
contents. 


322  ABDOMEN  AND  BACK. 

Cholecystostomy  when  the  Gall-bladder  is  Adherent  to 
the  Parietal  Peritoneum,  thus  Shutting  off  the  Peritoneal 
Cavity. — Having  made  the  incision  through  the  abdominal  wall 
as  described  above,  we  may  find  the  gall-bladder  adherent  to  the 
parietal  peritoneum,  thus  shutting  it  off  entirely  from  the  general 
peritoneal  cavity.  In  this  case  one  may  well  avoid  breaking  down 
the  adhesions,  and  proceed  at  once  to  open  and  empty  the  gall- 
bladder; a  drainage  tube  is  introduced  into  the  bladder  and  the  in- 
cision in  the  abdomen  is  left  open  and  packed. 

Cholecystostomy  when  the  Gall-bladder  Cannot  be 
Brought  up  into  the  Incision. — At  times  it  is  not  possible  to  draw 
the  gall-bladder  up  into  the  abdominal  incision  for  the  purpose  of 
fixing  it  to  the  edges  of  the  wound,  even  after  adhesions,  that  may 
be  present,  have  been  broken  up. 

Under  these  circumstances  it  may  be  better  to  extirpate  the 
gall-bladder,  or  else,  after  emptying  it  in  part  with  the  aspirator, 
it  may  be  freely  incised,  emptied,  and  thoroughly  disinfected.  A 
drainage  tube  may  then  be  introduced  into  the  bladder  and  fixed 
with  a  catgut  suture  (No.  2)  to  the  edge  of  the  opening  in  the  blad- 
der, and  in  addition  to  this  a  purse-string  suture  of  catgut  may  be 
placed  in  the  wall  of  the  gall-bladder,  close  to  the  margin  of  the 
opening,  which,  when  drawn  tight,  grasps  the  tube,  the  end  of  which 
is  allowed  to  project  through  the  incision  in  the  abdomen.  Finally, 
gauze  is  packed  into  the  abdominal  incision  around  the  tube,  reach- 
ing down  to  the  gall-bladder. 

Cholecystectomy. — Extirpation  of  the  gall-bladder. 

This  operation  may  be  done  in  cases  of  cholelithiasis  when  one 
is  unable  to  bring  the  gall-bladder  sufficiently  well  upward,  forward, 
to  sew  it  to  the  abdominal  incision;  for  rupture  of  the  gall-bladder, 
due  to  falls,  blows,  or  a  run-over.  One  must  always  be  certain  of 
the  patency  of  the  common  bile-duct  before  extirpating  the  gall- 
bladder. 

The  incision  is  vertical,  four  to  six  inches  long,  corresponding 
to  the  outer  border  of  the  rectus  muscle  and  commencing  above  at 
the  tip  of  the  ninth  costal  cartilage. 

After  the  abdomen  has  been  opened  the  gall-bladder  is  sought. 
It  may  be  distended  and  present  below  the  edge  of  the  liver,  or  it 
may  be  small  and  concealed  beneath  the  free  edge  of  the  liver. 

Adhesions  between  the  gall-bladder  and  neighboring  parts 
should  be  broken  up  with  the  fingers,  and  the  bile-ducts,  especially 


OPERATIONS  UPON  THE  GALL-BLADDER.  323 

the  common,  should  be  thoroughly  palpated,  since  extirpation  of  the 
gall-bladder  is-  naturally  counter-indicated  if  the  common  duct  is 
obstructed.  If  a  stone  is  found  in  the  common  duct  it  may  be 
crushed  with  padded  forceps  or  forced  back  into  the  bladder  or 
onward  into  the  duodenum,  or  it  may  be  removed  by  one  of  the 
operations  described  below. 

After  having  assured  one's  self  of  the  patency  of  the  common 
duct  one  may  proceed  with  the  extirpation  of  the  gall-bladder.  If 
the  gall-bladder  is  distended,  one  may  aspirate  for  the  purpose 
of  relieving  the  tension  and  to  discover  the  nature  of  the  con- 
tents. The  liver  is  drawn  upward  and  the  pylorus  downward  out  of 
the  way. 

The  layer  of  peritoneum  which  covers  the  inferior  aspect  of  the 
gall-bladder  and  binds  it  to  the  under  surface  of  the  liver  is  incised 
or  torn,  and  the  gall-bladder  separated  from  the  under  surface  of 
the  liver  subperitoneally,  and,  as  much  as  possible,  bluntly  with  the 
finger,  at  the  same  time  making  traction  upon  the  gall-bladder, 
which  is  held  in  the  grasp  of  a  forceps.  The  separation  of  the  gall- 
bladder is  commenced  at  the  fundus,  gradually  working  backward 
toward  the  neck  of  the  organ.  After  freeing  the  neck  one  continues 
along  the  cystic  duct  as  far  as  its  junction  with  the  common  duct; 
so  that  the  gall-bladder  finally  hangs  free,  suspended  only  by  the 
cystic  duct.  The  hemorrhage  from  the  raw  surface  of  the  liver  is 
usually  but  slight  and  may  be  controlled  by  a  few  minutes'  com- 
pression with  a  hot  gauze  pad  or  by  the  Paquelin,  if  necessary. 
A  double  silk  or  catgut  ligature  is  thrown  around  the  cystic  duct, 
close  to  its  junction  with  the  common  duct  and  tied,  and  the  cys- 
tic duct  then  divided  between  the  ligatures,  and  the  gall-bladder 
thus  removed.  The  stump  of  the  cystic  duct  is  drawn  into  the 
incision  by  the  ligature,  which  is  left  long  for  that  purpose,  and  cau- 
terized; the  ligature  is  then  cut  short  and  the  stump  allowed  to  drop 
back  into  the  abdomen.  The  edges  of  the  layer  of  peritoneum  which 
bound  the  gall-bladder  to  the  under  surface  of  the  liver,  and  which 
was  torn  to  allow  the  enucleation  of  the  gall-bladder,  may  be  brought 
together  with  a  catgut  suture,  thus  closing  in  the  raw  area  of  the 
liver  and  the  stump  of  the  cystic  duct. 

The  incision  in  the  abdomen  is  closed  without  drainage  with 
several  interrupted  silk-worm  gut  sutures,  the  edges  of  the  opening 
in  the  parietal  peritoneum  being  first  brought  together  in  the  usual 
way  with  a  continuous  catgut  suture. 


324  ABDOMEN  AND  BACK. 

Cholecyst-enterostomy.  —  The  formation  of  a  fistulous  opening 
between  the  gall-bladder  and  the  intestine  in  case  of  inoperable  ob- 
struction of  the  common  duct. 

A  vertical  incision  four  to  six  inches  long  is  made,  correspond- 
ing to  the  outer  border  of  the  right  rectus  muscle,  in  the  semilunar 
line,  commencing  above,  just  below  the  free  border  of  the  ribs  at  the 
tip  of  the  ninth  costal  cartilage. 

Having  cut  through  the  abdominal  wall,  the  distended  gall- 
bladder usually  presents.  It  is  aspirated  and  emptied  as  nearly  as 
possible  of  its  contents  and  then  incised,  and,  if  stones  are  present, 
these  are  removed;  it  is  then  packed  with  gauze  to  prevent  further 
escape  of  its  contents.  A  loop  of  the  jejunum,  sixteen  to  twenty 
inches  below  the  duodenum  (see  "G-astro-enterostomy"),  is  secured 
and  brought  up,  in  front  of  the  great  omentum  and  transverse  colon, 
into  the  incision  in  the  abdominal  wall. 

Gauze  pads  are  then  properly  placed  to  prevent  soiling  of  the 
peritoneal  cavity,  and  with  a  fine,  straight  needle  and  fine  silk  the 
gall-bladder,  at  a  convenient  point  near  its  fundus,  and  the  gut, 
opposite  its  mesenteric  border,  are  united  to  each  other.  This 
stitch  takes  a  good,  broad  bite,  including  the  serous  and  muscular 
coats,  but  does  not  pierce  the  whole  thickness  of  the  wall  of  either 
organ.  The  gall-bladder  and  jejunum  are  joined  together  in  this 
way  for  a  distance  of  about  one  and  one-half  inches.  This  needle 
is  then  temporarily  laid  aside,  and  an  incision  one  inch  long  is  made 
in  both  the  gall-bladder  and  the  intestine;  these  openings  are 
placed  opposite  each  other  and  are  shorter  than  the  line  of  suture 
which  has  already  been  applied.  "With  a  curved  surgeon's  needle 
and  silk  or  catgut  the  contiguous  edges  of  both  these  openings  are 
joined  together  all  around  with  a  continuous  overhand  stitch,  which 
penetrates  all  the  coats,  and  thus  the  communication  between  the 
two  organs  is  effected.  After  this  the  first  straight  needle  carrying 
the  fine  silk  thread,  with  which  the  first  half  of  the  "outside  serous 
suture"  was  made,  is  again  taken  up  and  the  second  half  of  this 
"outside  serous  suture"  is  introduced.  In  this  way  the  gall-bladder 
and  the  intestine  are  united  by  a  double  line  of  suture,  one  joining 
the  edges  of  the  openings  to  each  other  all  around,  and  the  other, 
a  non-penetrating  suture,  which  surrounds  this  first  suture  and 
buries  it. 

Having  thus  completed  this  part  of  the  operation,  the  opening 
which  was  made  in  the  fundus  of  the  bladder  for  the  purpose  of 


OPERATIONS  UPON  THE  GALL-BLADDER.  325 

emptying  it  and  removing  stones,  etc.,  may  be  closed  with  a  Lembert 
suture  of  fine  silk,  or  else  the  margins  of  this  opening  may  be  fixed 
to  the  edges  of  the  abdominal  incision  in  order  to  insure  drainage 
for  a  day  or  two  (cholecystostomy).  The  abdominal  wound  may  be 
closed  in  part,  that  portion  which  is  left  open  being  packed  (see 
"Cholecystostomy").  If  the  opening  in  the  gall-bladder  has  been 
closed,  then  the  abdominal  incision  may  be  likewise  closed. 

The  result  of  this  operation  is  the  establishment  of  a  commu- 
nication which  allows  the  bile  to  flow  from  the  gall-bladder  into  the 
intestine.  The  fistula  (cholecystostomy)  closes  readily.  The  dis- 
advantage of  this  operation  is  that  the  bile  enters  the  intestine  rather 
low  for  digestive  purposes.  This  objection  Avould  be  obviated  if  the 
communication  were  made  between  the  gall-bladder  and  the  duo- 
denum. This  anastomosis  may  also  be  effected  by  the  Murphy  button 
or  with  Laplace  forceps,  etc. 

Cholecysto-duodenostomy  with  Murphy  Button. — The  formation 
of  a  fistulous  opening  between  the  gall-bladder  and  the  duodenum, 
the  upper  part  that  adjoins  the  gall-bladder,  for  obstruction  in  the 
common  duct. 

A  vertical  incision  four  to  six  inches  long  is  made  from  the  tip 
of  the  ninth  costal  cartilage,  downward,  along  the  outer  border  of 
the  rectus  muscle,  in  the  linea  semilunaris,  or  a  vertical  incision 
(Murphy)  may  be  employed  which  commences  above,  just  below  the 
free  border  of  the  ribs  and  reaches  downward  for  a  distance  of  three 
or  four  inches;  this  incision  is  placed  two  inches  to  the  right  of  and 
parallel  with  the  middle  line,  penetrating  between  the  fibers  of  the 
rectus  muscle. 

Having  cut  through  the  abdominal  wall,  the  gall-bladder  is  lo- 
cated and  drawn  into  the  wound  and  steadied  there;  then  the  duo- 
denum is  secured  and  drawn  into  the  wound.  The  duodenum  is 
cleared  of  its  contents  by  gentle  stripping  with  the  fingers,  and  a 
compressor  applied  to  prevent  the  re-entrance  of  contents.  Pads  are 
arranged  to  protect  the  peritoneal  cavity,  and  with  a  fine,  straight 
needle  a  silk  thread  is  introduced  into  the  free  surface  of  the  gut  in 
the  fashion  of  a  purse-string.  This  suture  should  include  about  one 
and  one-half  inches  of  the  length  of  the  gut  and  be  in  a  straight  line; 
it  should  be  made  with  three  punctures  of  the  needle,  each  bite  in- 
cluding about  one-third  inch  and  passing  through  the  entire  thick- 
ness of  the  wall  of  the  gut;  a  second  similar  suture  line  is  then  made 
with  the  same  thread  in  the  reverse  direction  parallel  with  the  first 


326  ABDOMEN  AND  BACK. 

and  distant  from  this  rather  more  than  one-fourth  inch,  finally  ter- 
minating alongside  of  where  the  needle  first  entered  in  commencing 
the  suture  (see  Fig.  125).  Corresponding  to  the  point  where  the 
thread  turns  back  to  form  the  second  half  of  the  suture  a  little  slack, 
or  loop,  should  be  left.  With  the  ends  of  this  running  stitch  the  first 
loop  of  a  surgeon's  knot  is  taken.  The  gut  is  then  incised  between  the 
two  rows  of  suture  for  a  distance  corresponding  to  two-thirds  the 
length  of  the  diameter  of  the  button  to  be  used  (No.  1  or  2  preferable), 
the  incision  being  shorter  than  the  suture  line.  The  male  half  of  the 
button,  grasped  with  a  thumb  forceps,  is  then  slipped  sideways  into  the 
opening  in  the  gut  and  the  running  string  drawn  tight  about  it  and 
tied.  This  half  of  the  button  is  thus  fixed  in  the  opening  in  the  intes- 
tine and  steadied  until  the  female  half  has  been  fixed  in  the  gall- 
bladder. 

If  the  gall-bladder  is  distended,  one  may  first  empty  it  with 
the  aspirator.  A  similar  running  suture  and  incision  are  made  in 
the  gall-bladder  at  a  convenient  point  near  the  fundus,  and  any 
stones  that  are  present  may  be  extracted.  After  this  the  female 
half  of  the  button  is  introduced  into  the  opening  and  the  purse- 
string  drawn  tight  and  tied;  the  two  halves  of  the  button  are  then 
gently  and  steadily  forced  home. 

It  might  be  wise  in  addition  to  make  a  fistula  by  incising  the 
gall-bladder  and  sewing  the  edges  of  the  opening  thus  made  into  the 
abdominal  wound,  as  already  described  (cholecystostomy).  As  a 
rule,  this  is  unnecessary,  however,  and  the  abdominal  wound  may 
be  closed  without  drainage. 

The  anastomosis  between  the  gall-bladder  and  duodenum  may 
also  be  accomplished  with  suture  or  with  the  Laplace  forceps. 

OPERATIONS  UPON  THE  GALL=DUCTS. 

Choledochotomy.- — Incision  into  the  common  bile-duct. 

Choledocho-lithectomy.  —  Incision  into  the  common  duct  and 
removal  of  a  stone.  A  stone  may  be  found  impacted  in  the  common 
bile-duct  and  so  fixed  that  it  cannot  be  forced  onward  into  the  duo- 
denum. 

The  common  bile-duct  lies  fairly  deep  in  the  abdominal  cavity 
between  the  layers  of  the  lesser  omentum,  passing  down  behind  the 
first  part  of  the  duodenum.  If  it  contains  a  stone,  it  is  usually  found 
dilated,  pouched,  and  its  wall  thickened.     In   order  to   reach   the 


OPERATIONS  UPON  THE  GALL-DUCTS.  327 

common  duct  it  may  be  necessary  to  lengthen  the  usual  gall-bladder 
incision,  which  passes  downward  from  the  tip  of  the  ninth  rib,  and 
introduce  deep  abdominal  retractors;  the  liver  is  drawn  upward  and 
the  pylorus  pulled  downward  out  of  the  way.  The  hepatic  artery 
lies  to  the  left  of  the  duct  and  the  portal  vein  behind  it.  It  may  be 
necessary  to  separate  bluntly  with  the  fingers  adhesions  between  the 
neighboring  organs,  working  in  between  the  pyloric  end  of  the  stom- 
ach and  the  under  surface  of  the  liver. 

After  the  common  bile-duct  has  been  recognized  and  the  stone 
felt  within  it,  pads  are  properly  placed  to  isolate  the  field  of  opera- 
tion and  protect  the  rest  of  the  peritoneal  cavity.  The  duct  is  then 
incised  in  its  long  diameter  and  the  stone  extracted  whole  or  after 
crushing  it,  if  it  is  very  large.  Escaping  bile  is  caught  and  sponged 
away  with  gauze  pads.  After  the  duct  has  been  sponged  out  and 
the  adjoining  parts  disinfected  with  a  pad  moistened  with  alcohol, 
the  opening  may  be  closed  with  a  single  continuous  suture  of 
silk  that  includes  the  whole  thickness  of  the  edges  of  the  incision. 
This  will  usually  suffice,  but  it  may  be  reinforced  by  an  additional 
continuous  layer  of  Lembert  sutures  of  fine  silk.  If  in  doubt  as  to 
the  security  of  the  suture,  one  may  introduce  a  plug  of  gauze  through 
the  incision  in  the  abdomen  down  to  the  suture  line  in  the  duct  for 
the  purpose  of  drainage,  and  this  may  be  removed  after  forty-eight 
hours. 

Choledocho-lithotripsy. — Crushing  a  stone  within  the  common 
bile-duct  without  making  an  incision  into  the  duct. 

This  is  not  advisable  unless  the  calculus  is  quite  soft.  It  may 
be  done  with  padded  forceps. 

Duodenotomy  for  Removal  of  Stone  Impacted  in  the  Common 
Duct. — McBurney,  and  after  him  others,  have  removed  stones  of 
considerable  size,  which  had  become  impacted  low  down  in  the  com- 
mon duct,  through  an  opening  in  the  duodenum.  This  operation  is 
especially  adapted  to  the  removal  of  stones  impacted  low  down  in 
the  common  duct  near  its  duodenal  end;  they  may  present  into  the 
duodenum  through  the  mouth  of  the  duct. 

A  vertical  incision  about  five  inches  in  length  is  made  in  the 
abdomen,  commencing  above  at  the  tip  of  the  right  ninth  costal 
cartilage.  This  incision  corresponds  to  the  outer  margin  of  the 
rectus  muscle.  With  the  hand  in  the  abdomen,  the  diagnosis  may 
be  confirmed  by  feeling  the  stone  in  the  common  duct. 

The  greater  omentum  and  the  transverse  colon  are  drawn  up- 


328  ABDOMEN  AND  BACK. 

ward  out  of  the  way  and  the  second  part  of  the  duodenum  made 
accessible.  Several  gauze  pads  are  arranged  in  the  wound  to  shut 
off  the  rest  of  the  abdomen  from  the  field  of  operation,  and  deep 
retractors  then  introduced. 

A  vertical  incision  one  to  one  and  one-half  inches  long  is  made 
in  the  middle  of  the  descending  part  of  the  duodenum,  any  escaping 
intestinal  contents  being  wiped  away  with  gauze  pads.  Within  the 
duodenum  search  is  made  for  the  orifice  of  the  conjoined  common 
and  pancreatic  ducts.  This  is  found  on  the  inner  posterior  wall  of 
the  second  part  of  the  duodenum;  i.e.,  upon  that  part  of  the  wall 
of  the  duodenum  which  is  contiguous  io  the  pancreas  and  about 
four  inches  distant  from  the  pylorus. 

In  the  normal  subject  this  orifice  is  marked  by  a  papilla.  If  a 
stone  is  present  in  the  common  duct,  the  orifice  may  be  found  en- 
larged, with  the  stone  presenting  into  it,  or  a  probe  may  be  carried 
through  the  orifice  into  the  duct  and  the  stone  felt.  A  forceps  may 
be  introduced  through  the  orifice  into  the  duct,  and  the  stone 
grasped  and  withdrawn. 

In  order  to  extract  the  stone  it  may  be  necessary  to  dilate  the 
mouth  of  the  duct  or  to  nick  it  with  the  knife  or  scissors.  When  the 
stone  is  withdrawn  there  follows  a  free  flow  of  bile,  which  should  be 
mopped  away  as  fast  as  it  escapes. 

The  opening  in  the  duodenum  is  closed  with  a  row  of  silk  Lem- 
bert  sutures,  which  are  introduced  with  a  small,  curved  surgeon's 
needle  in  a  holder. 

The  incision  in  the  abdomen  is  closed  in  the  usual  way. 

THE  SPLEEN. 

The  Surgical  Anatomy  of  the  Spleen.  —  The  spleen  is  a  solid 
organ  located  in  the  upper  left  part  of  the  abdomen  in  close  relation 
with  the  fundus  of  the  stomach,  to  which  it  is  attached  by  the  gastro- 
splenic  ligament  (omentum),  being  suspended  from  the  diaphragm 
by  the  phrenico-splenic  ligament,  its  lower  end  resting  upon  the 
phrenico-colic  ligament.  The  spleen  is  rather  ellipsoidal,  although 
its  shape  may  vary.  It  measures  usually  about  12  cm.  in  its  long 
diameter,  8  cm.  in  breadth,  and  3  cm.  in  thickness.  Its  size  may  vary 
considerably. 

Its  outer  surface  is  smooth  and  rounded,  and  looks  outward, 
upward,  and  backward  toward  the  diaphragm,  which  separates  it 


OPERATIONS  UPON  THE  SPLEEN.  329 

from  the  pleura  and  the  edge  of  the  lung  and  the  ninth,  tenth,  and 
eleventh  ribs.  Its  inner  surface  consists  of  two  areas:  the  anterior, 
the  gastric  surface,  which  is  the  broader,  looks  inward  and  forward, 
and  lies  close  to  the  posterior  surface  of  the  fundus  of  the  stomach; 
the  posterior  portion  of  the  inner  surface  is  in  contact  with  the  upper 
and  outer  part  of  the  left  kidney  and  the  tail  of  the  pancreas.  Be- 
tween these  two  areas  the  inner  surface  presents  the  hilum,  where 
the  vessels  and  nerves  pass  in  and  out  of  the  organ. 

The  lower  end  of  the  spleen  is  in  relation  with  the  splenic  flex- 
ure of  the  colon,  and  rests  upon  the  phrenico-colic  ligament,  which 
supports  it.  The  anterior  border  is  rather  sharp,  and  marked  by  a 
varying  number  of  notches.  The  posterior  border  is  rounded  and 
thick. 

The  splenic  artery  is  a  branch  of  the  cceliac  axis,  and  in  its 
course  to  the  hilum  of  the  spleen  runs  along  the  upper  border  of 
the  pancreas,  lying  above  the  splenic  vein. 

The  splenic  vein  is  as  large  around  as  one's  finger — twice  as 
large  as  the  splenic  artery.  It  emerges  in  several  branches  from  the 
hilum  of  the  spleen,  runs  along  the  upper  border  of  the  pancreas, 
and  after  receiving  the  inferior  mesenteric  vein  joins  with  the  supe- 
rior mesenteric  to  form  the  portal  vein. 

The  spleen  is  almost  completely  invested  by  the  peritoneum, 
which  is  intimately  blended  with  the  firm  capsule  proper  of  the 
organ.  The  spleen  is  fixed  to  the  stomach  by  the  gastro-splenic 
ligament  (omentum)  and  to  the  diaphragm  by  the  phrenico-splenic 
ligament,  the  suspensory  ligament.  Its  lower  end  rests  upon  the 
phrenico-colic  ligament. 

The  gastro-splenic  ligament,  or  omentum,  is  the  fold  of  peri- 
toneum which  is  reflected  from  the  fundus  of  the  stomach  over  to  the 
spleen,  and  between  its  layers  the  splenic  vessels  pass  to  and  from  the 
hilum  of  the  spleen  and  the  vasa  brevia  to  the  fundus  of  the  stom- 
ach. The  phrenico-splenic  ligament,  or  suspensory  ligament,  is  the 
fold  of  peritoneum  which  is  reflected  from  the  diaphragm  to  the 
spleen. 

OPERATIONS  UPON  THE  SPLEEN. 

Splenotomy. — Incision  of  the  spleen  for  the  purpose  of  evac- 
uating an  abscess  or  an  hydatid  cyst. 

The  abdominal  incision  may  depend  upon  the  location  of  the 
tumor,  if  any  is  present.     Usually  the  incision  is  made  along  the 


330  ABDOMEN  AND  BACK. 

outer  edge  of  the  left  rectus,  in  the  semilunar  line  from  the  lower 
border  of  the  ribs  downward. 

After  having  cut  through  the  abdominal  wall  and  parietal  peri- 
toneum, if  the  spleen  is  found  adherent  to  the  parietal  peritoneum, 
thus  shutting  off  the  general  peritoneal  cavity,  one  may  incise  at 
-once  with  the  knife  or  Paquelin  cautery  and  drain.  If  adhesions, 
shutting  off  the  general  peritoneal  cavity,  are  not  present,  one  may 
pack  down  to  the  surface  of  the  spleen,  leaving  the  abdominal  incis- 
ion open  in  part,  and  only  after  adhesions  which  isolate  the  exposed 
splenic  surface  from  the  general  peritoneal  cavity  have  formed,  after 
from  two  to  five  days,  is  the  incision  into  the  organ  made. 

Splenectomy. — Extirpation  of  the  spleen;  for  wandering  spleen, 
wounds,  rupture,  prolapse,  hemorrhage,  or  sarcoma. 

The  incision  must  be  liberal — from  10  to  15  cm.  or  longer.  It 
may  be  placed  in  the  middle  line,  commencing  below  the  ensiform 
cartilage  and  passing  downward  and  around  the  left  side  of  the  um- 
bilicus, or  it  may  be  conveniently  placed  along  the  outer  border  of 
the  left  rectus  muscle  in  the  linea  semilunaris,  or,  if  there  is  a  tumor 
present,  the  incision  may  be  placed  to  correspond. 

After  the  abdomen  has  been  opened  and  the  hemorrhage  from 
the  edges  of  the  incision  controlled,  the  hand  is  introduced  into  the 
abdomen  and  the  spleen  seized.  If  adhesions  are  present,  these  may 
be  gently  broken  down  with  the  fingers,  or,  if  vascular,  they  may  be 
tied  double  with  catgut  and  cut.  If  the  capsule  of  the  spleen  is  not 
wounded,  one  should  avoid  injury  to  it,  as  this  will  save  considerable 
hemorrhage. 

After  the  spleen  has  been  freed  it  is  drawn  forward  into  the 
wound;  it  is  fixed  within  the  abdomen  by  the  peritoneal  folds,  which 
connect  it  to  the  stomach  and  to  the  diaphragm.  Its  pedicle,  which 
consists  practically  of  the  gastro-splenic  omentum  (including  the 
splenic  vessels),  may  be  transfixed,  through  its  middle,  with  a 
curved,  blunt-pointed  ligature  carrier,  provided  with  a  long  strand  of 
strong  silk  or  catgut.  This  ligature  is  then  cut  so  as  to  make  two,  and 
tied,  one  including  the  upper  half  of  the  pedicle  and  the  other  the 
lower  half.  One  should  avoid  including  the  tail  of  the  pancreas  in 
tying  these  ligatures.  These  ligatures  should  be  tied  tight  and  left 
long  to  serve  as  tractors  in  order  to  pull  the  stump  of  the  pedicle 
into  the  wound  for  final  inspection  after  the  spleen  has  been  cut 
away.  If  the  phrenico-splenic  ligament  is  not  included  in  the  liga- 
tures placed  as  indicated,  this  may  now  be  ligated  also  and  in  a 


SURGICAL  ANATOMY  OF  THE  PANCREAS.  331 

similar  manner.  The  pedicle  is  then  cut  through  close  to  the  spleen 
and  the  or-gan  removed;  the  stump  of  the  pedicle  may  be  drawn 
.gently  forward  and  an  effort  made  to  isolate  and  ligate  the  splenic 
•artery  and  vein,  each  separately.  If  the  pedicle  is  properly  secured 
there  is  little  danger  of  hemorrhage. 

The  wound  in  the  abdomen  is  closed  without  drainage,  first  bring- 
ing the  edges  of  the  parietal  peritoneum  together  with  a  continuous 
■catgut  suture  and  then  the  other  layers  with  interrupted  silk-worm  gut. 

THE   PANCREAS. 

Surgical  Anatomy  of  the  Pancreas. — The  pancreas  is  an  elon- 
gated glandular  organ  six  inches  long,  its  breadth  equal  to  about 
'one-fourth  its  length;  it  is  about  one-half  inch  in  thickness  from 
before  backward. 

It  is  placed  transversely  in  the  upper  back  part  of  the  abdom- 
linal  cavity,  lying  behind  the  stomach  across  the  body  of  the  second 
lumbar  vertebra. 

It  consists  of  a  head,  body,  and  tail,  the  tail  abutting  against  the 
■spleen. 

The  head  lies  to  the  right  of  the  vertebral  column,  resting  upon 
the  inferior  vena  cava,  right  crus  of  the  diaphragm,  and  right  renal 
vessels,  and  separated  from  the  inner  border  of  the  right  kidney  by 
the  second  part  of  the  duodenum.  The  common  bile-duct  is  located 
'between  the  second  part  of  the  duodenum  and  the  head  of  the 
(pancreas. 

The  body  of  the  pancreas  lies  opposite  the  second  lumbar  ver- 
tebra upon  the  crus  (left)  of  the  diaphragm,  aorta,  thoracic  duct,  etc. 
'To  the  left  of  the  vertebral  column  it  is  in  relation  with  the  renal 
•vessels  and  left  kidney.  In  front  of  the  pancreas  are  the  perito- 
neum, stomach,  and  transverse  colon. 

The  splenic  artery  and  vein  run  along  its  upper  border.  Its 
"lower  border  is  in  relation  with  the  third  part  of  the  duodenum,  and 
passing  forward  between  this  part  of  the  duodenum  and  the  lower 
"border  of  the  pancreas  are  the  superior  mesenteric  artery  and  vein. 

The  tail  of  the  pancreas  projects  to  the  left  as  far  as  the  spleen, 
to  which  it  is  connected  by  a  fold  of  peritoneum,  ligamentum  pan- 
<creatico-lienale. 

The  pancreas  is  covered  by  the  peritoneum  upon  its  anterior 
surface  only.     The  transverse  mesocolon  passes  backward,  and  upon 


332  ABDOMEN  AND  BACK. 

reaching  the  pancreas  its  layers  separate;  the  upper  layer  passes- 
upward,  covering  the  front  surface  of  the  pancreas,  and  lines  the 
hack  wall  of  the  upper  part  of  the  abdomen  (lesser  sac). 

The  duct  of  the  pancreas  courses  through  the  organ  from  left  to 
right,  and  opens  into  the  second  part  of  the  duodenum,  through  an 
orifice  which  it  has  in  common  with  the  common  bile-duct  (see- 
"Conimon  Bile-duct"). 


OPERATIONS  UPON  THE  PANCREAS. 

Injuries  of  the  abdomen  involving  the  pancreas  are,  from  their 
very  nature,  usually  associated  with  such  serious  injuries  to  the 
neighboring  organs  that  death  results  without  special  regard  to  the- 
pancreas. 

Parts  of  the  pancreas  may  be  tied  off  and  excised.  Abscess 
and  tumor  of  the  pancreas  may  cause  obstruction  of  the  intestine 
through  pressure  and  adhesions. 

Abscess  of  the  pancreas  may  be  opened  from  in  front  through 
an  incision  in  the  anterior  abdominal  wall  or  it  may  be  incised  be- 
hind, extraperitoneally.  If  opened  from  in  front,  the  contents  of 
the  sac  may  be  evacuated  with  an  aspirator  in  part  and  the  envelop- 
ing wall  of  the  abscess  or  cyst  cavity  then  sewed  to  the  edges  of  the 
abdominal  wound,  or,  without  evacuating,  the  sac  may  be  fixed  to  the- 
edges  of  the  incision  in  the  abdomen  and  opened  later  after  adhe- 
sions have  formed. 

A  retention  cyst  may  be  due  to  occlusion  of  the  pancreatic  duct 
by  stone.  Hydatid  cysts  may  also  be  found  in  the  pancreas.  These 
are  incised  and  drained  through  an  incision  in  the  middle  line  above 
the  umbilicus;  the  cyst  wall  may  be  sewed  to  the  edges  of  the  incis- 
ion in  the  abdomen  and  opened  later  after  adhesions  have  formed. 

• 

OPERATIONS  UPON  THE  SPINAL  COLUMN. 

Laminectomy. — Kesection  of  the  laminge  of  the  vertebras  for  the 
purpose  of  relieving  compression  of  the  cord  due  to  traumatism  or 
disease,  depressed  or  displaced  bone,  extravasated  blood,  pus,  tuber- 
culous products,  Pott's  disease,  tumors,  etc. 

The  patient  is  placed  prone  upon  the  table  with  a  shallow  cush- 
ion under  the  ribs  to  give  the  back  a  slight  curve.  A  long  incision 
is  made,  in  the  middle  line,  through  the  soft  parts  down  to  the  tips- 


OPERATIONS  UPON  THE  SPINAL  COLUMN.  333 

of  the  spinous  processes.  The  middle  of  this  incision  should  corre- 
spond to  the  probable  location  of  the  injury  or  disease. 

The  soft  parts — muscles,  etc. — upon  either  side  of  the  middle 
line  are  then  freely  separated  with  a  periosteum  elevator  so  as  to 
expose  the  laminge  of  from  three  to  five  vertebras. 

Hemorrhage  should  be  controlled;,  oozing,  by  temporary  press- 
ure of  a  pad,  etc.,  and  spurting  points  by  clamps  and  ligatures. 
The  spinous  processes  may  be  snipped  off  at  their  bases  with  the 
cutting  bone  forceps,  the  blades  of  which  may  be  conveniently  bent 
at  an  obtuse  angle. 

While  the  soft  parts,  detached  muscles,  etc.,  are  well  retracted, 
the  laminae,  if  not  already  fractured  by  a  traumatism,  are  divided 
and  then  removed. 


Pig.  137.— Keen  Bone  Forceps.    The  end  of  the  upper  blade  is  fenestrated. 

The  laminae  that  are  to  be  resected  should  first  be  stripped 
bare  of  their  periosteum  and  any  remaining  soft  parts  with  the 
sharp-edged  periosteum  elevator,  and  then  divided  as  close  as  pos- 
sible to  the  transverse  processes,  first  on  one  side  and  then  on  the 
other.  The  laminae  may  be  divided  with  a  Hays  saw,  chisel,  or 
rongeur  forceps,  or  they  may  be  gnawed  through  with  a  Keen  for- 
ceps. The  laminae  which  correspond  to  the  middle  of  the  wound 
are  first  resected  and  then  those  of  the  vertebras  above  and  below. 
In  this  way  the  spinal  canal  is  opened  and  in  some  cases  of  trauma- 
tism the  compression  will  have  been  relieved. 

The  dura  mater  proper  is  exposed  by  tearing  with  a  blunt 
director  through  the  loose  connective  tissue  that  overlies  the  dura. 
In  thus  exposing  the  dura  mater,  there  may  be  considerable  hemor- 
rhage from  the  venous  plexus  that  is  located  in  the  posterior  part  of 


334  ABDOMEN  AND  BACK. 

the  vertebral  canal  between  the  bony  wall  and  the  dura,  but  this  is 
readily  controlled  by  a  few  minutes'  compression  with  a  gauze  pad. 
As  already  mentioned,  after  the  spinal  canal  has  been  opened,  the 
immediate  cause  of  the  symptoms  may  present  itself  and  the  con- 
dition may  be  remedied  without  opening  the  dura;  for  example, 
a  dislocated  vertebra,  tuberculous  granulation  tissue,  extradural 
tumor,  etc.  Prominent  angular  deformity  of  the  anterior  wall  of 
the  spinal  canal  due  to  fracture,  dislocation,  Pott's  disease,  should 
be  corrected  by  reduction  or  by  chiseling  or  gouging  away  the  offend- 
ing process  of  bone;  carious  bone  may  be  curetted  and  sequestra 
removed. 

In  order  to  reach  the  anterior  wall  of  the  canal,  it  may  be 
necessary  to  divide  several  nerve-trunks  upon  one  side  and  lift  the 
cord  partly  out  of  its  bed.  The  severed  nerves  may  be  reunited 
afterward  by  suture. 

If  the  cause  of  the  symptoms  is  not  apparent  the  dura  should 
be  laid  open.  Before  opening  the  dura,  its  color,  degree  of  bulging, 
pulsation,  etc.,  should  be  noted.  The  dura  is  picked  up  with  a 
toothed  forceps  and  a  small  opening  made  in  the  middle  line,  and 
through  this  opening  the  dura  is  incised  upon  a  grooved  director  te 
any  requisite  length.  When  the  dura  is  incised  there  is  an  escape 
of  cerebro-spinal  fluid  and  may  be  pus  or  blood.  Adhesions 
between  the  dura  mater  and  the  arachnoid  should  be  gently  broken 
up.  The  edges  of  the  dura  may  be  then  well  retracted  and  the  cord 
carefully  examined.  A  bent  probe  may  be  used  to  investigate  the 
sides  and  anterior  aspect  of  the  cord. 

In  closing  the  wound  the  edges  of  the  dura  are  brought  together 
with  interrupted  catgut  sutures  placed  about  one-eighth  inch  apart,, 
and  the  edges  of  the  muscles  and  skin  approximated  with  inter- 
rupted sutures  of  silk-worm  gut.  For  the  purpose  of  drainage,  a 
narrow  strip  of  gauze  is  introduced  into  the  bottom  of  the  wound,  its 
extremity  emerging  through  the  lower  end  of  the  skin  incision.  The 
wound  usually  heals  by  first  intention. 

The  parts  should  be  immobilized  by  incasing  the  patient  in, 
plaster  or  by  the  use  of  a  proper  extension  apparatus. 

Lumbar  Puncture. — J.  Leonard  Corning,  of  New  York,  in  1885 
reported  experiments  of  injecting  solutions  of  cocairi  into  the  spinal 
canal  through  a  puncture  in  the  dorsal  region  for  the  purpose  of  in- 
ducing analgesia,  etc. 

Quincke,  of  Kiel,  in  1891,  practiced  lumbar  puncture  for  the 


OPERATIONS  UPON  THE  SPINAL  COLUMN.  335. 

purpose  of  drawing  off  fluid  to  diminish  intracranial  pressure  in 
eases  of  hydrocephalus.  With  this  object  in  view  he  has  drawn  off 
as  much  as  100  c.c.  in  some  cases. 

Bier  in  1899  reported  a  number  of  cases  which  had  heen  oper- 
ated upon  painlessly  under  the  influence  of  cocain  introduced  into 
the  subarachnoid  space  through  a  lumbar  puncture. 

Tuffier  in  1899  brought  the  matter  prominently  before  the  gen- 
eral profession,  and  since  then  the  method  has  been  practiced  by 
many  operators  with  varying  degrees  of  satisfaction. 

The  necessary  instruments  consist  of  a  needle  and  a  syringe. 
The  needle  should  be  about  10  cm.  long,  with  a  diameter  of  about 
1.1  mm.  and  with  a  canal,  or  bore,  of  0.8  mm.  The  point  of  the- 
needle  should  be  sharp,  but  the  bevel  should  be  short.  The  needle 
throughout  may  be  made  of  steel  or  its  body  may  be  made  of  a  flex- 
ible alloy  and  its  extremity  of  steel.  Such  a  needle  would  bend, 
without  breaking  (Bainbridge).  The  syringe  should  have  a  capacity 
of  30  minims,  and  be  so  constructed  as  to  permit  of  proper  ster- 
ilization; a  glass  barrel  with  a  solid  metal  piston  would  answer. 
The  nozzle  of  the  syringe  and  the  cap  of  the  needle  should  form  a 
smooth  bevel  joint, — not  a  screw  thread, — in  order  to  permit  of 
their  rapid  adjustment  and  to  eliminate  the  use  of  washers. 

The  puncture  may  be  made  between  the  laminae  of  the  fourth 
and  fifth  lumbar  vertebrae  or  between  the  third  and  fourth  or  the 
fifth  and  first  sacral.  The  puncture  between  the  laminae  of  the 
fourth  and  fifth  seems  to  be  preferred  by  most  surgeons. 

The  needle  is  introduced  just  below  and  to  the  right  of  the  tip  of 
the  spinous  process  of  the  fourth  lumbar  vertebra  and  is  pushed  in  a 
direction  forward  and  inward  and  slightly  upward  into  the  spinal, 
canal. 

The  patient  should  be  seated  upon  the  side  of  the  table  with 
his  back  to  the  operator,  his  trunk  bent  forward,  and  his  elbows 
resting  upon  the  thighs.  The  tips  of  the  spinous  processes  should 
form  a  straight  line  from  above  downward,  deviating  neither  to  the- 
right  nor  left. 

To  locate  the  tip  of  the  spinous  process  of  the  fourth  lumbar 
vertebra,  which  is  the  guide  in  performing  the  operation,  a  line  may 
be  drawn  across  the  back  from  the  highest  point  of  one  iliac  crest 
to  a  corresponding  point  upon  the  other.  The  tip  of  the  spinous 
process  of  the  fourth  lumbar  will  be  found  to  correspond  to  this  line. 

The  patient  being  bent  forward  causes  the  space  between  the- 


336  ABDOMEN  AND  BACK. 

lamina  of  the  fourth  and  fifth  lumbar  vertebrae  to  become  wider. 
The  index  finger  of  the  left  hand  is  placed  upon  the  lower  part  of 
the  tip  of  the  spinous  process  of  the  fourth  lumbar  vertebra,  and 
with  the  right  hand  the  needle  is  introduced;  it  is  entered  just 
below  and  about  1  cm.  to  the  right  of  this  point  (tip  of  the  spine  of 


Fig.  138. — Lumbar  Puncture.  Tip  of  spinous  process  of  fourth  lumbar 
vertebra  corresponds  to  a  line  drawn  across  the  back  touching  the  highest 
point  of  each  iliac  crest.  The  needle  is  inserted  just  below  and  to  right  of 
the  tip  of  the  spinous  process  of  the  fourth  lumbar  vertebra. 

the  fourth  lumbar).  The  skin  may  be  anaesthetized  and  a  small  in- 
cision made  with  the  point  of  the  knife  in  order  to  permit  the 
easy  passage  of  the  needle  through  this  structure,  which  is  some- 
times pretty  tough  and  difficult  to  penetrate.  The  needle  is  then 
pushed  slowly  and  deliberately  forward  and  inward  through  the 
soft  parts,  entering  the  spinal  canal  in  the  middle  line  between  the 


OPERATIONS  UPON  THE  SPINAL  COLUMN.  337 

laminas  of  the  fourth  and  fifth  lumbar  vertebras.  After  the  needle 
has  passed  through  the  ligament  between  the  laminae,  ligamentum 
subflavum,  and  the  dura  mater  into  the  subarachnoid  space  there 
is  felt  a  sense  of  diminished  resistance  which  is  readily  appreciated, 
especially  by  the  experienced.  The  positive  proof  that  the  extrem- 
ity of  the  needle  is  in  the  subarachnoid  space  is  the  escape  of  the 
clear  cerebro-spinal  fluid,  which  flows  from  the  end  of  the  needle 
drop  by  drop.  Not  more  than  about  ten  drops  of  the  cerebro-spinal 
fluid  should  be  allowed  to  escape.  The  syringe  containing  the  co- 
cam  solution  which  is  to  be  introduced  is  now  adjusted  to  the  needle 
and  its  contents  slowly  injected.  From  15  to  20  minims  of  a  2-per- 
cent, solution  is  the  quantity  usually  injected. 

Unless  the  escape  of  cerebro-spinal  fluid  occurs  to  indicate  pos- 
itively that  the  end  of  the  needle  is  in  the  subarachnoid  space  the 
injection  should  not  be  made. 

If  the  needle  strikes  an  impediment,  bone,  on  the  way,  it  should 
be  partly  withdrawn  and  its  direction  changed  so  as  to  avoid  the 
obstruction.  One  should  not  attempt  to  forcibly  change  the  course 
of  the  needle  by  bending  it  without  withdrawing  it  at  least  in  part, 
as  it  may  break  off;  a  sudden  movement  or  jerk  on  the  part  of  the 
patient  may  also  break  the  needle.  With  the  flexible  needle  of 
Bainbridge  this  danger  is  eliminated. 


PART  VI. 

THE  RECTUM. 


Surgical  Anatomy  of  the  Rectum.  —  The  rectum  is  the  ter- 
mination of  the  alimentary  canal  and  is  contained  within  the  true 
pelvis,  the  posterior  wall  of  which  is  formed  hy  the  sacrum  and 
coccyx. 

The  Sackum  is  an  irregular,  triangular-shaped  bone  formed 
hy  the  coalescence  of  five  vertebras.  With  the  coccyx  it  forms  the 
lower  part  of  the  vertebral  column  and  the  posterior  wall  of  the 
pelvis,  where  it  is  wedged  in  between  the  ossa  innominata. 

It  is  flattened  from  before  backward  and  curved  upon  itself, 
and  is  placed  very  obliquely,  so  that  its  anterior  surface  looks  down- 
ward as  well  as  forward.  Above,  it  articulates  with  the  fifth  lumbar 
vertebra,  forming  a  prominent  angle  which  projects  forward  and 
forms  the  back  part  of  the  inlet  into  the  true  pelvis.  Its  lower  end 
articulates  with  the  base  of  the  coccyx.  The  lateral  borders  of  the 
sacrum  are  broad  and  irregular  above,  for  articulation  with  the  iliac 
bones  and  for  the  attachment  of  the  posterior  sacro-iliac  ligaments. 
The  lower  part  of  the  lateral  border  is  thin,  and  gives  attachment 
to  the  greater  and  lesser  sacro-sciatic  ligaments  and  to  a  portion  of 
the  gluteus  maximus  muscle.  Its  anterior  surface  is  smooth,  con- 
cave, looks  downward  and  forward,  and  presents  on  either  side,  one 
below  the  other,  the  four  anterior  sacral  foramina,  through  which 
openings  the  anterior  sacral  nerves  escape  from  the  sacral  canal. 
The  branches  which  emerge  from  the  first,  second,  and  third  ante- 
rior sacral  foramina  are  large  and  go  to  form  the  sacral  plexus. 
Through  the  fourth  anterior  sacral  foramina  emerge  nerves  which 
are  distributed  to  the  rectum  and  the  bladder. 

The  posterior  surface  of  the  sacrum  is  convex,  rough,  and  irreg- 
ular. In  the  middle  line  from  above  downward  are  three  or  four 
tubercles,  which  represent  the  corresponding  spinous  processes; 
usually  the  fourth  and  always  the  fifth  are  absent.  External  to  the 
spinous  processes,  on  either  side  of  the  middle  line,  are  the  four 
posterior  sacral  foramina,  one  below  the  other.  These  provide  exit 
to  the  posterior  sacral  nerves,  which  are  of  no  importance  surgically. 
Between  the  posterior  sacral  foramina  and  the  spinous  processes  the 
(338) 


SURGICAL  ANATOMY  OF  THE  RECTUM.  339 

bone  is  smooth,  and  corresponds  to  the  laminae  of  the  other  verte- 
bra?, forming'  the  posterior  wall  of  the  sacral  canal;  the  laminae  of 
the  fourth  -usually  and  of  the  fifth  always  are  absent,  thus  leav- 
ing the  sacral  canal  open  at  its  lower  part.  The  margins  of  the 
laminae  below,  where  the  canal  is  open,  are  prominent,  and  are  called 
the  cornua.  They  articulate  with  the  corresponding  cornua  of  the 
coccyx.  The  posterior  surface  of  the  sacrum  is  covered  by  and  gives 
attachment  to  the  erector  spina?  muscle. 

The  Coccyx  is  formed  of  four  rudimentary  vertebrae,  and  con- 
tains no  spinal  canal.  Below,  at  the  tip,  the  coccyx  is  pointed  and 
gives  attachment  to  the  sphincter  ani.  Above,  it  presents  a  base 
with  a  prominent  process  on  each  side,  the  cornu.  Its  base  artic- 
ulates with  the  lower  end  of  the  sacrum;  its  cornua  articulate  with 
those  of  the  sacrum.  Its  lateral  border  gives  attachment  to  the 
greater  and  lesser  sacro-sciatic  ligaments,  to  the  coccygeus  muscle, 
and  low  down  near  its  tip  to  a  few  fibers  of  the  levator  ani  muscle. 

The  Rectum  is  continuous  with  the  sigmoid  flexure  and  ter- 
minates at  the  anus.  It  is  about  eight  inches  long,  and  is  located  in 
the  back  part  of  the  true  pelvis,  surrounded  by  loose  connective 
tissue.  It  includes  that  part  of  the  large  intestine  which  reaches 
from  the  left  sacro-iliac  synchondrosis  to  the  anus.  It  is  usually 
described  as  consisting  of  three  parts. 

The  first,  or  upper,  part  of  the  rectum  extends  from  the  left 
sacro-iliac  synchondrosis  toward  the  middle  line,  and,  dipping  into 
the  pelvis  in  front  of  the  sacrum,  becomes  continuous,  opposite  the 
second  sacral  vertebra,  with  the  second,  or  middle  part.  This  upper 
part  of  the  rectum  is  narrower  than  the  middle  portion,  and  com- 
prises about  one-half  its  entire  length.  It  is  provided  with  a  com- 
plete investment  of  peritoneum,  which,  as  mesorectum,  is  attached 
to  the  front  of  the  sacrum,  and  thus  serves  to  suspend  the  rectum  in 
the  pelvis.  Dipping  down  into  the  pelvis,  behind  the  rectum,  be- 
tween the  folds  of  the  mesorectum,  is  the  termination  of  the  inferior 
mesenteric  artery,  which  is  known  as  the  superior  hemorrhoidal. 
This  part  of  the  rectum  is  in  relation  behind  with  the  left  sacro- 
iliac synchondrosis  and  the  front  of  the  sacrum.  Interposed  be- 
tween it  and  the  sacrum  are  the  pyriformis  muscle,  the  sacral  plexus 
of  nerves,  and  the  left  internal  iliac  vessels  and  their  branches. 
Anteriorly  it  is  covered  by  the  peritoneum,  and  is  in  relation  with 
some  coils  of  small  intestine. 

The  second,  or  middle,  part  of  the  rectum  is  more  roomy  than 


340  RECTUM. 

the  first  part,  and  is  known  as  the  ampulla;  it  corresponds  to  the 
front  of  the  sacrum  and  coccyx,  reaching  from  the  second  sacral 
vertebra  to  the  tip  of  the  coccyx.  It  is  curved,  with  its  concavity 
forward.  This  part  of  the  rectum  is  covered  only  upon  its  anterior 
aspect  by  the  peritoneum.  In  the  male  the  peritoneum  is  reflected 
from  this  part  of  the  rectum  forward  on  to  the  bladder,  which  it 
reaches  just  above  the  seminal  vesicles  (see  Fig.  177).  In  the  female 
the  peritoneum  reaches  lower  down  upon  the  front  surface  of  the 
rectum  than  in  the  male,  and  is  reflected  from  this  organ  forward 
upon  the  upper  fourth  of  the  posterior  wall  of  the  vagina  and  upon 
the  uterus,  forming  the  pouch  of  Douglas.  This  pouch  often  con- 
tains coils  of  small  intestine  and  in  the  female  may  contain  a  dis- 
placed ovary. 

In  the  male  the  lower  part  of  this  middle  portion  of  the  rectum 
is  in  relation  with  the  base,  or  trigone,  of  the  bladder,  the  latter 
lying  directly  in  front  of  the  rectum.  Between  the  base  of  the 
bladder  and  this  part  of  the  rectum  are  the  seminal  vesicles  and  the 
prostate  gland,  and  here  upon  either  side  the  ureters  enter  the 
bladder.  In  the  female  the  lower  portion  of  this  part  of  the  rectum 
is  in  relation  with  the  posterior  wall  of  the  vagina. 

The  third,  or  lowest,  part  of  the  rectum  is  that  portion  which 
extends  from  the  tip  of  the  coccyx  to  the  anus,  and  is  directed  down- 
ward and  backward;  it  has  no  relation  whatever  with  the  peritoneal 
cavity.  In  the  male  the  perineum  separates  this  third  portion  of 
the  rectum  from  the  urethral  canal,  and  in  the  female  from  the 
lower  part  of  the  vagina.  This  part  of  the  rectum  is  rather  narrow, 
and  corresponds  to  the  location  of  the  sphincters.  Upon  either  side 
of  this  part  of  the  rectum,  the  levator  ani,  which  extends  downward 
and  inward  from  its  origin  along  the  lateral  wall  of  the  true  pelvis, 
is  attached. 

Besides  the  antero-posterior  curves  already  described  the  rec- 
tum presents  a  lateral  curve.  The  first  part  of  the  rectum  in  dipping 
into  the  pelvis  from  the  left  sacro-iliac  synchondrosis  reaches  a 
little  to  the  right  of  the  middle  line,  while  the  lower  part  lies  a 
little  to  the  left  of  the  middle  line. 

The  lumen  of  the  rectum  presents  three  half-moon  folds,  or 
plicae  sigmoidea,  with  corresponding  constrictions  on  its  outer  surface. 
These  folds  contain  muscular  fibers.  The  most  marked  and  constant 
of  these  folds,  plica  transversalis  recti,  is  located  about  half-way  up 
upon  the  right  wall,  5  to  6  cm.  from  the  anal  orifice  and  upon  a 


SURGICAL  ANATOMY  OF  THE  RECTUM.  341 

level  with  Douglas's  fold.  The  two  others  are  upon  the  left  wall, 
not  so  constant  nor  so  prominent,  and  are  placed  one  nearer  and  the 
other  farther  away  from  the  anus  than  the  one  first  mentioned. 
These  folds  may  offer  considerable  obstruction  to  the  passage  on- 
ward of  bougies,  etc. 

In  the  lower  part  of  the  rectum  the  mucous  membrane  is 
thrown  into  longitudinal  folds, — columns  Morgagni, — so  that  upon 
section  it  would  present  a  star-shaped  appearance.  About  one  inch 
above  the  anal  opening  the  circular  muscular  fibers  are  increased 
in  number  and  aggregated  into  a  bundle — the  sphincter  internus; 
this  is  composed  of  unstriped  muscular  fibers. 

Surrounding  the  anal  orifice  and  attached  behind  to  the  tip  of 
the  coccyx  and  in  front  to  the  midpoint  of  the  perineum  is  the  col- 
lection of  muscular  fibers  which  is  known  as  the  sphincter  externus; 
this  is  formed  of  striped  voluntary  muscular  fibers. 

The  skin  about  the  anus  is  thrown  into  folds,  which  radiate 
toward  the  anus,  and  often  in  the  form  of  tags,  etc.,  may  become 
hypertrophied,  inflamed,  and  itch — external,  or  itching,  piles;  or 
they  may  present  cracks  and  fissures  between  them,  at  the  edge  of 
the  anus — fissure  in  ano. 

The  rectum  is  supplied  by  the  superior  hemorrhoidal  artery, 
the  termination  of  the  inferior  mesenteric.  This  vessel  descends 
behind  the  rectum  between  the  folds  of  the  mesorectum,  and  op- 
posite the  middle  of  the  rectum  divides  into  two  branches;  these 
distribute  branches  upon  the  sides  of  the  rectum  almost  to  the  lower 
end.  One  may  cut  into  the  posterior  wall  of  the  rectum  (strictures, 
etc.)  for  a  distance  of  about  three  inches  above  the  anal  orifice  with- 
out meeting  this  vessel.    It  bifurcates  above  this  point. 

The  middle  hemorrhoidal  branches  are  derived  from  the  in- 
ternal iliac.  The  inferior  hemorrhoidal,  several  on  each  side,  are 
derived  from  the  internal  pudic  (branch  of  the  internal  iliac)  as  it 
courses  forward  upon  the  inner  aspect  of  the  tuber  ischii;  they  pass 
inward  toward  the  anus  and  beneath  the  skin,  and  supply  the  in- 
tegument about  the  anus  and  the  lower  end  of  the  rectum;  these 
branches  are  divided  when  incisions  are  made  in  this  region  in  the 
skin  or  into  the  ischio-rectal  fossa?.  The  branches  from  these  three 
sets  of  vessels  anastomose  freely  with  each  other  up  and  down  the 
rectum. 

The  veins  of  the  rectum  form  a  plexus  of  interanastomosiug 
branches  upon  the  wall  of  the  rectum;   they  terminate  above  in  the 


342  RECTUM. 

superior  hemorrhoidal,  which  empties  into  the  inferior  mesenteric, 
which  in  turn  empties  into  the  portal.  The  middle  and  inferior 
hemorrhoidal  veins  empty,  the  middle  into  the  internal  iliac  and  the 
inferior  into  the  internal  pudic.  Thus  the  rectum  is  liberally  sup- 
plied with  arterial  blood  from  both  the  inferior  mesenteric  and  the 
internal  iliac  arteries,  the  branches  from  both  freely  anastomosing 
with  each  other;  it  is  drained  by  venous  branches  which  carry  blood 
to  both  the  portal  and  general  circulation,  these  also  freely  inter- 
communicating with  each  other. 

The  venous  plexus  situated  in  the  lower  part  of  the  rectum, 
just  above  the  anus  and  beneath  the  mucous  membrane,  is  tortuous, 
and  in  certain  conditions — disturbance  of  the  portal  circulation, 
habitual  constipation,  pressure  of  the  gravid  uterus,  etc. — may  be- 
come enlarged,  pouched,  and  varicose,  and  give  rise  to  the  condition 
known  as  "bleeding  piles,"  or  internal  hemorrhoids.  Through  the 
veins  which  drain  the  rectum  infection  may  be  carried  to  the  liver 
— abscess  of  the  liver,  etc. 

The  nerves  that  emerge  from  the  first,  second,  and  third  ante- 
rior sacral  foramina  join  with  each  other  to  form  the  sacral  plexus. 
The  rectum  is  supplied  by  nerves  that  emerge  through  the  fourth 
anterior  sacral  foramen.  Branches  from  these  nerves  are  also  dis- 
tributed to  the  bladder. 

OPERATIONS  UPON  THE  RECTUM. 

Dilatation  of  the  Sphincter. — This  operation  is  practiced  as  a 
curative  measure  for  fissure  in  ano  and  as  a  preliminary  step  in  other 
operations  upon  the  anus  and  rectum. 

The  patient  is  placed  in  the  lithotomy  position.  Under  anaes- 
thesia two  fingers  or  the  thumb  of  each  hand  are  introduced  through 
the  anus  and  well  up  into  the  rectum  beyond  the  level  of  the  internal 
sphincter,  and  a  gradually  increasing  steady  force  is  exerted  in  a 
lateral  direction  toward  either  tuber  ischii  until  the  sphincter  is 
thoroughly  relaxed.  Considerable  force  may  be  employed,  but  it 
should  be  applied  gradually,  and  not  abruptly. 

Fistula  in  Ano. — This  may  be  either  complete  or  incomplete. 
The  incomplete  may  be  either  blind  external  or  blind  internal. 

A  complete  fistula  is  a  tract,  or  sinus,  which  opens  internally 
into  the  rectum  and  externally  upon  the  skin  near  the  margin  of 
the  anus,  and  may  allow  the  escape  of  gas  and  faeces  from  the  bowel. 


OPERATIONS  UPON  THE  RECTUM. 


343 


The  opening  into  the  rectum  is  usually  single,  but  there  may  be 
several  openings  upon  the  skin. 

If  the  finger  is  introduced  into  the  rectum  and  a  probe  passed 
into  the  fistula  through  the  opening  in  the  skin,  its  point  may  be 
felt  beneath  the  rectal  mucous  membrane  and  may  be  guided 
through  the  inner  orifice  of  the  fistula  into  the  rectum.  This  open- 
ing will  be  found  a  variable  distance  above  the  anal  orifice  and  at 
times  may  be  somewhat  difficult  to  discover;  it  may  be  located  above 
the  internal  sphincter  or  it  may  be  just  above  the  external  sphincter 
close  to  the  margin  of  the  anus. 

An  incomplete,  or  blind,  fistula  is  one  which  presents  an  orifice 
at  only  one  end.     If  it  opens  into  the  rectum,  but  not  externally 


Fig.  139.— Complete  Fist- 
ula in  Ano.  M,  muscular 
layer  of  the  rectum;  M.M. 
mucous  membrane  layer  of 
rectum ;  SE,  cross  section 
of  external  sphincter;  81, 
cross  section  of  internal 
sphincter. 


Fig.  140.—  Blind  Internal 
Fistula.  Arrow  indicates 
opening  from  rectum.  For 
letters,   see  Fig.   139. 


Fig.  141.— Blind  External 
Fistula.  Arrow  shows  open- 
ing upon  the  skin.  For 
letters,   see  Fig.  139. 


upon  the  skin,  it  is  called  a  blind  internal  fistula;  if  it  opens  ex- 
ternally upon  the  skin,  but  not  internally  into  the  rectum,  it  is  called 
a  blind  external  fistula. 

Operation  for  Complete  Fistula. — The  anus  is  first  thor- 
oughly stretched.  The  finger  is  then  introduced 'into  the  rectum 
and  a  blunt-pointed  grooved  director  passed  into  the  fistula  through 
the  opening  in  the  skin.  The  point  of  the  director,  which  may  be 
recognized  by  the  finger  in  the  rectum  beneath  the  rectal  mucous 
membrane,  is  guided  into  the  bowel  through  the  internal  orifice  of 
the  fistula.  It  is  important  to  find  this  opening.  The  end  of  the 
director  is  then  brought  out  through  the  anus, — the  director  may 
be  bent  somewhat  in  order  to  do  this, — and  the  bridge  of  tissue 
upon  the  director  is  divided  with  the  knife,  carried  along  the  groove 


344  RECTUM. 

of  the  director;  the  fistula  is  thus  laid  open  through  its  whole 
length  into  the  rectum.  If  there  is  more  than  one  external  orifice 
upon  the  skin,  the  intervening  tissue  between  the  separate  open- 
ings should  be  divided.  Any  secondary  sinuses  branching  off 
from  the  main  fistulous  tract  should  also  be  laid  open.  As  the  in- 
ternal orifice  of  the  fistula  is  above  the  external  sphincter  or  may 
be  above  the  internal  sphincter,  these  muscles  are  naturally  divided 
when  the  fistula  is  laid  open.  One  may  curette  the  tract  of  the  sinus 
after  it  has  been  laid  open,  but  too  much  force  should  not  be  used. 
The  whole  wound  is  finally  packed  with  iodoform  gauze.  This  pack- 
ing should  not  be  too  tight,  but  should  reach  well  to  the  bottom  of 
the  wound  in  every  direction.  The  bleeding  is  usually  readily  con- 
trolled by  the  packing.  Any  spurting  vessels  should  be  clamped  and 
tied  or  the  clamps  may  be  left  on  until  the  first  dressing. 

Operation  for  Incomplete  Fistula  is  practically  the  same 
as  the  foregoing.  If  there  is  no  opening  into  the  rectum, — a  blind 
external  fistula, — the  point  of  the  director,  which  is  passed  into  the 
fistula  through  the  external  orifice  and  which  is  felt  beneath  the 
rectal  mucous  membrane  by  the  finger  within  the  rectum,  may  be 
forced  into  the  rectum,  the  sinus  being  thus  converted  into  a  com- 
plete fistula,  and  the  parts  then  divided  as  already  described. 

If  there  is  no  external  opening, — a  blind  internal  fistula, — we 
make  one.  The  skin  about  the  margin  of  the  anus  at  the  point 
corresponding  to  the  blind  external  extremity  of  the  fistulous  tract 
is  usually  marked  by  redness,  induration,  etc.  After  the  skin  has 
been  incised  at  this  point,  thus  converting  the  sinus  into  a  com- 
plete fistula,  it  is  treated  as  above  described. 

Hemorrhoids.  External,  or  Itching,  Piles  present  them- 
selves about  the  margin  of  the  anal  orifice  outside,  external  to  the 
sphincter;  they  consist  of  cutaneous  tags,  which  may  be  snipped 
off  with  the  scissors,  the  edges  of  the  skin  being  then,  if  necessary, 
brought  together  with  a  single  suture.  Occasionally  they  contain 
a  varicosed  vein,  which  may  be  thrombosed;  this  may  be  laid  open, 
the  clot  turned  out,  and  the  edges  of  the  skin  brought  together  with 
one  or  two  catgut  stitches. 

Frequently  a  fissure  is  located  at  the  base  of  one  of  these  ex- 
ternal tags,  or  piles,  and  it  is  therefore  wise,  in  all  these  cases,  to 
stretch  the  sphincter  before  removing  the  pile. 

Internal,  or  Bleeding,  Piles. — These  are  located  entirely 
within  the  anus,  only  appearing  externally  when  the  patient  strains, 


OPEEATIONS  UPON  THE  RECTUM. 


345 


or  bears  down.  They  may  be  caught  in  the  grasp  of  the  sphincter 
and  become-  strangulated.  When  the  patient  strains  they  may  ap- 
pear as  one  or  more  fairly  well  defined  bunches.  Each  mass  consists 
of  a  bunch  of  dilated,  pouched,  varicose  veins  covered  over  by  mu- 
cous membrane  which  may  be  normal  in  appearance  or  may  be  more 
or  less  ulcerated. 

Ligation  and  Excision. — The  sphincter  is  first  stretched  and 
the  rectum  thoroughly  irrigated.  Each  individual  hemorrhoidal 
mass  is  then  seized  with  a  clamp,  an  ordinary  artery  forceps,  and 
while  it  is  pulled  down  the  mucous  membrane  around  its  base  is  cut 
through  by  snipping  with  the  blunt-pointed  scissors.  This  incision 
should  extend  through  the  mucous  membrane  into  the  submucous 


Pig.  142. — Hemorrhoids.  E,  hemorrhoidal  mass  (internal  piles),  consist- 
ing of  a  bunch  of  tortuous  veins  covered  by  mucous  membrane  protrud.ng 
through  the  anal  orifice;  M,  muscular  layer  of  the  rectum;  M.M.,  mucous 
membrane  layer  of  rectum;  SE,  cross  section  of  external  sphincter  muscle; 
81,  cross  section  of  internal  sphincter  muscle;  SM,  submucous  layer  in  which 
the  veins  ramify;  *,  loose  connective  tissue  to  either  side  of  lower  end  of 
rectum  in  ischio-rectal  fossa. 


connective  tissue  layer,  but  should  not  cut  into  the  vessels  that  go 
to  form  the  hemorrhoidal  mass.  After  this  the  mucous  membrane 
at  the  base  of  the  pile  may  be  peeled  back  with  the  finger-nail  or 
the  end  of  the  scissors,  and  the  base  or  pedicle  of  the  pile  surrounded 
with  a  strong  catgut  ligature;  this  should  be  tied  very  tight  so  that 
it  cannot  slip  (No.  2  plain  catgut).  The  pile  is  cut  away  close  to 
the  ligature  and  the  ligature  then  cut  short.  Each  hemorrhoidal 
mass  that  presents  itself  is  treated  in-  like  manner.  They  usually 
vary  from  two  to  four  in  number.  The  edges  of  each  opening  may 
be  brought  together  over  the  stump  of  the  pile  with  one  or  two  cat- 
gut sutures,  but  this  is  probably,  in  most  cases,  unnecessary. 

After  the  operation  has  been  completed  strip  gauze  is  packed 


346  RECTUM. 

into  the  rectum  fairly  tight.  It  should  reach  to  a  point  above  the 
level  of  the  site  of  the  operation.  Instead  of  the  strip  gauze  one 
may  introduce  a  tampon  in  the  shape  of  a  square  piece  of  gauze,  the 
center  of  which  is  seized  with  a  forceps  and,  pouch-like,  pushed  into 
the  rectum  beyond  the  site  of  the  operation,  and  then  into  this  gauze 
pouch  strips  of  gauze  or  a  wad  of  cotton  may  be  packed.  The  pack- 
ing is  to  guard  against  hemorrhage  from  the  slipping  of  a  faulty 
ligature.  One  should  bear  in  mind  that  the  patient  may  suffer  con- 
siderable hemorrhage  into  the  bowel  without  any  blood  appearing 
externally;    hence  the  importance  of  carefully  tamponing. 

Clamp  and  Cautery. — After  the  anus  has  been  stretched,  etc., 
each  pile  is  seized  at  its  most  prominent  part  with  an  artery  forceps 
and  drawn  well  down  and  a  special  clamp — pile  clamp — applied  to 
its  base.  The  end  of  the  clamp  as  it  grasps  the  pile  should  be  di- 
rected upward  into  the  rectum;  i.e.,  it  should  not  grasp  the  hemor- 
rhoidal mass  along  a  line  parallel  with  the  margin  of  the  anus,  as 
this  would  result  in  an  annular  scar,  which  is  not  desirable.  The  pile 
should  be  firmly  caught  between  the  blades  of  the  clamp  and  secured 
by  turning  the  screw  down  tight.  The  pile  is  then  cut  away  with 
the  scissors,  rather  close  to,  but  not  flush  with,  the  surface  of  the 
blades  of  the  clamp;  a  small  part  of  the  tissue  should  be  left  pro- 
truding beyond  the  surface  of  the  clamp  after  the  pile  is  cut  away. 
The  cautery  at  a  red  heat  is  now  applied  to  the  cut  edge  of  the  re- 
maining portion  of  the  pile  which  protrudes  beyond  the  surface  of 
the  blades  of  the  clamp  and  this  is  slowly  burned  to  a  crisp  down  to 
the  surface  of  the  blades.  The  clamp  is  then  removed.  Each  pile 
is  treated  in  this  manner.     It  is  unnecessary  to  tampon  the  rectum. 

Excision  of  a  Circumscribed  Part  of  the  Rectal  Wall. — Before 
proceeding  with  this  operation  the  bowel  should  be  thoroughly  emp- 
tied by  a  course  of  laxatives  and  thorough  irrigation  of  the  rectum. 
This  preparatory  treatment  may  well  occupy  several  days  to  a  week. 
The  ease  with  which  a  limited  portion  of  the  rectal  wall  is  excised 
depends  upon  the  situation  of  the  disease. 

If  the  Disease  Involves  the  Lower  Part  of  the  Bowel 
situated  at  or  near  the  anus,  the  operation  is  comparatively  easy. 
The  sphincter  is  first  thoroughly  stretched  so  that  it  is  completely 
relaxed.  The  tumor  or  diseased  area  is  seized  with  a  vulsella  forceps 
or  the  fingers  and  is  drawn  down  and  out  through  the  anal  orifice, 
and  may  then  be  excised,  together  with  that  part  of  the  rectal  wall 
which  forms  its  base,  with  the  scissors  or  a  sharp  knife.     The  hem- 


OPERATIONS  UPON  THE  RECTUM.  347 

orrhage  should  be  controlled,  seizing  or  tying  bleeding  points  as  they 
are  encountered,  and  the  edges  of  the  defect  in  the  rectal  wall 
brought  together  by  suture  step  by  step  as  the  operation  progresses. 
The  wound  in  the  rectal  wall  should  be  closed  in  a  transverse  direc- 
tion, because  if  sewed  in  a  vertical  line  we  may  get  a  troublesome 
diminution  of  the  caliber  of  the  bowel,  and  this  should  be  avoided  in 
this  narrow  part.  The  stitches  should  be  of  catgut  and  interrupted, 
and  should  pass  through  the  whole  thickness  of  the  wall  of  the  bowel; 
the  ends  of  the  sutures  should  be  left  long  to  serve  as  tractors  to 
facilitate  the  placing  of  the  succeeding  sutures.  After  the  diseased 
part  has  been  entirely  removed  additional  sutures  may  be  placed 
between  those  already  introduced,  but  these  should  pass  only  through 
the  mucous  and  submucous  layers  of  the  bowel,  and  are  for  the  pur- 
pose of  giving  a  more  exact  union  of  the  edges  of  the  mucous  mem- 
hrane. 

If  the  Disease  is  Located  Highee  up,  Beyond  the  Region 
of  the  Anus. — The  field  of  operation  must  be  made  accessible  to 
view  and  touch,  if  possible;  but  this  is  more  difficult  than  is  the  case 
when  the  disease  is  located  lower  down,  nearer  the  anus. 

The  sphincter  should  be  forcibly  dilated,  so  that  it  is  entirely 
Telaxed.  The  tumor  or  diseased  area  may  then  be  seized  with  a 
vulsella  forceps,  and  can  often  be  pulled  down  and  out  through  the 
anal  orifice,  under  which  circumstances  the  operation  may  be  done 
practically  as  described  for  disease  situated  lower  down,  in  the  anal 
region.  Usually,  however,  the  stretching  of  the  anal  orifice  does  not 
suffice  to  allow  access  to  the  diseased  area,  and  we  may  find  it  de- 
sirable to  make  an  incision,  from  within  the  bowel,  through  the 
posterior  wall  of  the  rectum,  including  the  anus,  back  to  the  coccyx. 
In  this  way  we  may  make  the  field  of  operation  accessible.  Occa- 
sionally, however,  even  with  this  posterior  incision,  we  are  still  un- 
able to  bring  the  disease  within  easy  reach,  or  we  may  wish  to  avoid 
this  posterior  incision.  Under  these  circumstances  the  work  must 
be  done  within  the  rectum  with  the  aid  of  retractors.  For  this  pur- 
pose, after  the  sphincter  has  been  thoroughly  dilated,  two  flat-bladed 
retractors  are  introduced  well  up  into  the  rectum,  one  on  either  side, 
the  mucous  membrane  that  tends  to  prolapse  between  the  blades  of 
the  retractors  being  held  back  with  a  pad  upon  a  long  sponge  holder. 
One  should  thus  be  able  to  see  the  field  of  operation,  and  this  is  nec- 
essary in  order  to  control  the  hemorrhage  and  to  suture  the  edges 
■of  the  wound  which  is  left  in  the  rectal  wall  after  the  diseased  por- 


348  RECTUM. 

tion  has  been  extirpated.  The  retractors  being  in  position,  the  dis- 
eased area  is  seized  with  a  vulsella  forceps  and  excised  as  already  de- 
scribed. The  portion  of  the  rectum  immediately  above  the  anal 
region  is  roomy,  and  one  may  suture  the  woimd  left  in  this  part  of 
the  rectal  wall,  after  the  excision  of  the  disease,  in  a  vertical  direc- 
tion without  fear  of  constriction.  The  sutures  should  be  of  simple 
catgut,  and  the  ends  of  each  should  be  left  long  t-o  serve  as  tractors 
to  facilitate  the  introduction  of  the  succeeding  sutures;  when  the 
operation  is  complete  they  are  all  cut  short.  The  stitches  should  be 
interrupted;  every  second  stitch  should  pass  through  the  whole 
thickness  of  the  rectal  wall  and  the  intermediate  ones  through  the 
mucous  membrane  and  submucous  layers  only. 

If  an  accessory  posterior  incision  has  been  made  through  the 
wall  of  the  rectum  back  to  the  coccyx  this  part  of  the  wall  of  the 
rectum  should  also  be  closed  in  a  similar  manner,  but  the  back  part 
of  this  posterior  incision  which  opens  through  the  skin  behind  the 
anus,  between  it  and  the  coccyx,  should  be  left  partly  open  for  the 
purpose  of  drainage.  The  drainage  is  arranged  by  inserting  a  strip 
of  gauze,  which  is  packed  into  the  wound  behind  the  rectum  and  well 
up  as  far  as  the  site  of  the  suture  line.  This  packing  should  not  be 
tight,  but  should  surely  reach  to  the  bottom  of  the  wound. 

Volkmann  strongly  advises  drainage  in  all  cases  of  excision  of  a 
portion  of  the  wall  of  the  rectum  even  where  the  wall  of  the  rectum 
has  not  been  split  by  the  posterior  incision.  In  those  cases  where  the 
posterior  incision  through  the  rectal  wall  has  been  made  one  may 
drain  as  described  above.  If  the  posterior  incision  has  not  been 
made,  one  may  make  an  incision  in  the  skin  near  the  margin  of  the 
anus,  and  through  this  penetrate  sufficiently  deep  to  reach  the  site 
of  the  suture  line  in  the  wall  of  the  rectum  when  a  strip  of  gauze  is- 
introduced. 

Innocent  Rectal  Polypi. — After  the  anus  has  been  dilated  these 
may  be  seized  with  a  clamp  and  twisted  off  the  wall  of  the  rectum 
with  great  ease  or  they  may  be  amputated  with  the  cautery.  They 
usually  do  not  bleed,  but,  if  they  do,  the  stump  may  be  clamped  and 
tied. 

Extirpation  of  the  Rectum,  Amputatio  Recti  (Volkmann).— 
Special  pains  should  be  taken  to  thoroughly  empty  the  bowel,  espe- 
cially above  the  point  of  constriction,  with  a  course  of  laxatives  and 
copious  rectal  irrigations.  This  preparatory  treatment  may  require 
several  days  or  a  week. 


OPERATIONS  UPON  THE  RECTUM.  349 

This  operation  is  adapted  to  those  cases  in  which  the  disease 
has  already -involved  the  lower  part  of  the  rectum,  including  the 
anus — where  the  lower  end  of  the  bowel  (sphincter)  cannot  be  saved. 
The  diseased  portion,  including  the  anal  part,  is  amputated,  and 
after  this  has  been  accomplished  the  upper  part  of  the  gut  is  pulled 
down  and  sutured  to  the  margin  of  the  skin  about  the  anus. 

The  patient  is  placed  in  the  lithotomy  position.  A  strip  of  gauze 
may  first  be  introduced  into  the  rectum  to  prevent  leakage,  etc.,  and 
then  an  incision  which  encircles  the  anus  is  made  through  the  skin. 
This  incision  is  carried  down  into  the  loose  connective  tissue  about 
the  lower  end  of  the  rectum,  and,  when  this  part  of  the  bowel  has 
been  liberated  all  around,  it  is  seized  and  drawn  down.  The  levatores 
ani,  which  are  inserted  into  the  sides  of  the  lower  part  of  the  rectum, 
are  encountered.  These  are  divided  with  the  knife  or  scissors  close 
to  the  wall  of  the  rectum,  and  then,  gradually  working  deeper  and 
deeper,  the  rectum  is  thoroughly  separated  all  around  from  the  loose 
connective  tissue  which  surrounds  it,  and  pulled  down  more  and  more 
as  this  step  of  the  operation  progresses.  The  isolation  of  the  rectum 
is  accomplished  chiefly  by  dissecting  with  the  fingers  or  with  blunt- 
pointed  scissors. 

If  more  space  is  required,  accessory  incisions  may  be  added.  A 
posterior  incision  which  reaches  from  the  circular  incision  that  sur- 
rounds the  anus  backward  to  the  tip  of  the  coccyx  may  be  made. 
This  incision  may  still  farther  be  extended  upward  upon  the  back 
of  the  coccyx,  and,  if  necessary,  this  bone  may  be  enucleated,  after 
the  soft  parts  which  cover  it  have  been  separated  with  a  periosteum 
elevator.  An  anterior  incision  may  also  be  added;  this  passes  for- 
ward from  the  circular  incision  which  surrounds  the  anus  as  far  as 
the  bulb  of  the  urethra  in  the  male  and  the  posterior  wall  of  the 
vagina  in  the  female.  This  anterior  incision  not  only  provides  more 
room,  but  allows  the  operator  to  keep  himself  informed  of  the  loca- 
tion of  the  urethra  and  vagina,  and  may  thus  diminish  the  liability 
of  injuring  these  parts.  A  catheter  may  be  introduced  into  the 
bladder  as  an  additional  caution.  These  accessory  incisions  should 
not  extend  through  the  wall  of  the  rectum,  as  it  is  advisable  to  am- 
putate the  rectal  tube  intact,  without  cutting  into  it,  in  order  to 
avoid  soiling  the  wound  with  its  contents. 

In  liberating  the  rectum  in  the  female  we  have  to  separate  it 
upon  its  anterior  aspect  from  the  posterior  wall  of  the  vagina.  The 
vagina  may  also  be  involved  in  the  disease,  and  it  will  then  be  nee- 


350  RECTUM. 

essary  to  excise  a  part  of  its  wall  together  with  the  rectum.  In  this 
case  one  should  pause  and  close  the  opening  made  in  the  vaginal 
wall  before  proceeding  further  with  the  isolation  of  the  rectum.  In 
the  male  the  rectum  has  to  be  separated  anteriorly  from  the  pros- 
tate and  from  the  base  of  the  bladder. 

As  we  continue  deeper  with  the  isolation  of  the  rectum  upon  its 
anterior  aspect,  especially  if  the  disease  reaches  pretty  well  up,  we 
meet  the  fold  of  peritoneum  which  dips  down  in  front  of  the  rectum: 
in  the  female  between  the  rectum  and  the  vagina,  in  the  male  be- 
tween fne  rectum  and  the  bladder.  The  depth  to  which  this  peri- 
toneal fold  is  reflected  upon  the  front  wall  of  the  rectum  varies. 
Usually  it  descends  to  a  level  which  is  just  above  a  point  that  can 
be  reached  by  the  finger  introduced  into  the  rectum  through  the 
anus;  i.e.,  to  a  point  5  to  6  cm.  above  the  anus.  This  fold  may, 
however,  extend  down  to  a  point  within  a  short  distance  of  the  anus. 
If  this  fold  of  peritoneum  is  not  involved  in  the  disease,  it  may  be 
simply  stripped  away  from  the  front  wall  of  the  rectum  without 
opening  into  it.  At  times,  however,  it  is  opened,  either  intentionally 
when  it  is  diseased  or  accidentally.  This  is  of  no  special  significance, 
especially  if  the  rectum  itself  has  not  been  opened.  The  opening  in 
the  peritoneum  may  be  closed  at  once.  If  small,  its  edges  may  be 
caught  in  an  artery  clamp  and  tied  with  a  catgut  ligature  as  one 
ties  a  bleeding  vessel.  If  larger,  its  edge  may  be  sewed  to  the  peri- 
toneum that  covers  the  front  wall  of  the  rectum  with  several  catgut 
stitches,  or  it  may  be  left  unsutured  and  packed  with  gauze.  In 
separating  the  rectum  posteriorly  there  may  be  considerable  hemor- 
rhage. All  bleeding  vessels  should  be  clamped  as  they  are  cut.  Dis- 
eased glands  which  lie  behind  the  rectum  may  also  be  enucleated. 

After  having  separated  the  rectum  beyond  the  upper  limits  of 
the  disease  the  whole  tube  is  pulled  down  and  steadied  with  the 
vulsella  forceps,  which  serve  as  tractors,  grasping  the  bowel  above 
the  level  of  the  disease,  and  then  the  lower  diseased  portion  is  am- 
putated, making  a  straight  cut  transversely  across  the  bowel.  After 
this  has  been  done  the  edge  of  the  bowel  is  sewed  to  the  edges  of 
the  skin  around  the  anus  with  alternating  superficial  and  deep 
stitches  of  silk.  Before  the  edge  of  the  bowel  is  sewed  to  the  margins 
of  the  skin  about  the  anus  it  may  be  twisted  on  its  long  axis  through 
a  quarter  of  a  circle.  This  may  make  the  artificial  anus  somewhat 
more  retentive  (Gersuny).  If  twisted  to  a  greater  degree,  it  may  re- 
sult in  gangrene  of  the  lower  part  of  the  bowel. 


OPERATIONS  UPON  THE  RECTUM.  351 

If  there  have  been  made  accessory  posterior  and  anterior  in- 
cisions, thes.e  may  be  closed  with  several  interrupted  sutures;  but 
this  closure  should  not  be  complete,  as  there  should  be  sufficient 
space  between  the  sutures  to  allow  free  drainage  from  the  parts  about 
the  rectum. 

Drainage  is  made  with  strips  of  gauze,  which  are  packed  loosely 
into  the  incision,  both  in  front  and  behind  the  rectum. 

Resection  of  the  Rectum  in  Continuity  (Dieffenbach). — This  op- 
eration may  be  performed  for  excision  of  cicatricial  stricture  (Hal- 
sted). 

This  operation  is  applicable  to  those  cases  where  the  disease 
involves  the  wall  of  the  rectum  above  the  sphincter,  the  lower  portion 
of  the  tube  being  free  and  healthy. 

The  diseased  portion  of  the  rectum  is  resected  in  its  continuity 
and  the  lower,  end  of  the  upper  healthy  segment  then  sutured  to  the 
upper  end  of  the  lower  healthy  anal  part,  which  includes  the  sphinc- 
ter. The  Kraske  method  of  resecting  the  rectum  is  probably  prefer- 
able to  this  method,  especially  if  the  parts  outside  the  rectum  are 
involved. 

After  the  sphincter  has  been  thoroughly  dilated  the  lower, 
healthy  part  of  the  rectum  is  divided  into  two  lateral  halves  by  two 
incisions,  one  of  which,  commencing  within  the  rectum,  passes  back- 
ward, dividing  the  lower  part  of  the  rectum,  including  the  anus,  back 
to  the  coccyx.  The  second  incision  divides  the  front  wall  of  the 
rectum,  passing  forward  through  the  perineum  as  far  as  the  bulb  of 
the  urethra  in  the  male  and  the  posterior  wall  of  the  vagina  in  the 
female.  Both  these  incisions  reach  upward  through  the  wall  of  the 
rectum  to  a  point  just  below  the  lower  limits  of  the  disease.  Two 
broad,  blunt-pronged  retractors  are  then  introduced,  one  on  either 
side,  and  the  wound  thus  held  wide  open. 

In  either  lateral  half  of  the  rectum  which  has  been  thus  split 
and  just  below  the  lower  limits  of  the  disease  a  transverse  incision 
is  now  made.  This  incision  passes  through  the  entire  thickness  of 
the  rectal  wall,  and  separates  the  lower  healthy  part  of  the  rectum 
from  the  upper  diseased  portion.  Into  these  lateral  incisions  upon 
either  side  of  the  rectum  the  blunt-pronged  retractors  are  intro- 
duced, and,  after  inserting  a  strip  of  gauze  into  the  diseased  portion 
to  prevent  its  contents  from  soiling  the  wound,  the  lower  cut  edge  of 
the  upper  diseased  portion  of  the  rectum  is  secured  with  vulsella 
forceps  or  silk  tractor  sutures,  which  at  the  same  time  close  its  lower 


352  RECTUM. 

end,  and  its  isolation  from  the  loose  connective  tissue  by  which  it  is 
surrounded  upon  all  sides  is  commenced.  Steadily  drawing  the  dis- 
eased portion  of  the  bowel  more  and  more  downward,  its  separation 
from  the  adjoining  connective  tissue  is  continued  until  it  is  entirely 
free  and  we  are  able  to  reach  beyond  the  upper  limits  of  the  disease. 
This  separation  of  the  rectum  is  accomplished  chiefly  by  blunt  dis- 
section with  the  finger  or  the  end  of  the  blunt-pointed  scissors,  work- 
ing all  the  time  fairly  close  to  the  rectal  wall.  Vessels  are  clamped 
as  they  are  cut  during  the  course  of  the  operation.  All  spurting 
vessels  should  be  ligated. 

In  liberating  the  rectum  anteriorly  we  may  meet  the  fold  of 
peritoneum  that  projects  downward  upon  its  front  aspect.  If  this 
is  not  involved  in  the  disease  it  can  usually  be  peeled  away  from  the 
wall  of  the  rectum  with  the  finger  without  opening  into  it.  If  dis- 
eased, or  if  it  cannot  be  separated  from  the  front  wall  of  the  rectum, 
we  may  cut  through  it  close  to  the  wall  of  the  rectum,  and,  intro- 
ducing the  ringer  into  the  opening  thus  made,  draw  the  rectum  down. 
A  pad  may  be  temporarily  introduced  to  prevent  the  prolapse  of  in- 
testine through  the  opening  and  to  protect  the  peritoneal  cavity. 
After  the  rectum  has  been  drawn  down  for  a  sufficient  distance  the 
opening  in  the  peritoneum  may  be  closed  by  suturing  its  edge  with 
catgut  to  the  peritoneal  layer  that  covers  the  anterior  wall  of  the 
rectum,  or  it  may  be  left  unsutured  and  drained  with  a  strip  of  gauze, 
which  is  left  protruding  through  the  wound  in  the  perineum  in  front 
of  the  anus.  The  part  of  the  rectum  above  the  disease  should  not 
be  separated  from  its  surrounding  parts  any  more  than  is  absolutely 
necessary  to  permit  its  being  drawn  down  to  the  edge  of  the  lower 
segment  of  the  bowel,  and  furthermore  one  should  not  work  too  close 
to  the  wall  of  the  rectum  in  order  not  to  damage  the  blood-supply  to 
such  a  degree  that  the  nutrition  of  the  rectum  might  be  seriously 
impaired. 

After  the  rectum  has  been  liberated  to  a  point  beyond  the  upper 
limits  of  the  disease  we  may  then  proceed  to  excise  the  diseased  por- 
tion. Before  doing  this  two  tractors  of  silk  are  passed  through  the 
whole  thickness  of  the  wall  of  the  rectum  above  the  diseased  area  in 
order  to  steady  it  and  to  hold  it  after  the  diseased  segment  has  been 
excised.  When  this  has  been  accomplished  the  end  of  the  healthy 
bowel  is  drawn  down  and  sutured  to  the  upper  edge  of  the  lower  seg- 
ment (anal  portion).  This  is  done  with  fine  silk  sutures  which 
alternately   pass   through   the   whole    thickness    of   the    bowel    and 


OPERATIONS  UPON  THE  RECTUM.  353 

through  the  mucous  membrane  only.  The  edges  of  the  anterior  and 
posterior  incisions  in  the  lower  segment  of  the  rectum,  including  the 
ends  of  the  sphincter,  are  then  brought  together  in  a  similar  manner, 
and  thus  the  continuity  of  the  bowel  is  restored.  The  incision  in  the 
skin  in  front  of  the  anus  and  that  behind  the  anus  are  only  partly 
closed,  and  a  strip  of  gauze  is  packed  to  the  bottom  of  each  incision, 
as  thorough  drainage  is  imperative.  Before  commencing  the  suture 
of  the  bowel  the  parts  may  be  irrigated  and  a  soft  rubber  tube  sur- 
rounded by  gauze  introduced  well  up  into  the  upper  part  of  the 
rectum  beyond  the  proposed  site  of  suture.  This  is  to  prevent  soil- 
ing of  the  suture  line,  and  also  to  allow  the  passage  of  gas  and  pos- 
sibly fluid  fasces  during  the  few  days  immediately  following  the 
operation. 

If  the  peritoneal  pouch  has  been  opened  and  packed  the  end 
of  the  gauze  packing  emerges  through  the  incision  in  the  perineum 
in  front  of  the  anus. 

Eesection  and  Amputation  of  Rectum  through  the  Sacral  Route 
(Kraske). — This  method  is  well  adapted  for  resectio  recti  for  disease 
situated  high  up,  but  with  the  lower  end  of  the  rectum  and  the  anus 
still  healthy.  It  also  furnishes  the  best  route  for  amputatio  recti  in 
those  cases  where  the  anal  portion  is  also  involved. 

The  bowel  should  be  thoroughly  emptied  before  the  operation 
by  a  course  of  laxatives  and  repeated  rectal  irrigations.  This  prepar- 
atory treatment  should  be  thorough,  and  may  require  one  or  two 
weeks.  If  the  stricture  of  the  rectum  is  so  tight  that  the  bowel 
above  the  site  of  the  constriction  cannot  be  emptied  before  the 
operation,  one  may  do  a  preliminary  colostomy.  This  should  be  done 
one  or  two  weeks  before  the  rectal  operation.  The  transverse  colon 
should  be  used  for  this  purpose,  because  if  the  sigmoid  or  the  de- 
scending colon  is  used  there  may  be  some  difficulty  in  drawing  down 
the  bowel  at  the  time  of  the  rectal  operation. 

For  Resectio  Recti  (the  anal  portion  being  healthy). 

The  operation  is  described  in  three  steps: — 

1.  Sacral  "Vor  operation":  resection  of  the  coccyx  and  part  of 
the  sacrum. 

2.  Resection  of  the  diseased  portion  of  the  bowel. 

3.  Apposition  of  the  ends  of  the  bowel  and  treatment  of  the 
incision,  etc. 

Sacral  "Vor  Operation." — The  patient  lies  upon  the  left  side 
(Hochenegg),  with  the  belly  inclined  somewhat  toward  the  table,  the 


354 


RECTUM. 


lower  limbs  strongly  flexed  at  the  knees  and  hips,  and  supported  thus 
by  an  assistant,  or  he  may  rest  upon  the  abdomen  with  the  lower 
limbs  hanging  over  the  end  of  the  table.  A  slightly  curved  incision 
with  the  concavity  toward  the  left  is  made.  It  begins  above  on  a 
level  with  the  middle  of  the  sacrum  and  from  two  to  three  fingers' 
breadth  (about  two  inches)  to  the  left  of  the  middle  line;  it  is  carried 
down  to  the  middle  of  the  upper  border  of  the  coccyx,  and  from  this 
point  it  is  continued  down  in  the  middle  line  upon  the  coccyx,  ending 
at  its  tip.  This  incision  divides  the  skin,  subcutaneous  fat,  and  super- 
ficial fascia,  and  exposes  in  the  upper  part  of  the  wound  the  lower  por- 
tion of  the  gluteus  maximus  muscle,  the  fibers  of  which  run  at  right 
angles  to  the  line  of  the  incision. 


^^ 


Fig.  143.— Incision  for  Resection  of  the  Rectum  (Kraslie). 


That  part  of  the  gluteus  maximus  muscle  which  presents  itself 
in  the  wound  is  incised  and  retracted,  and  there  are  then  exposed, 
lying  underneath,  the  attachment  to  the  sacrum  of  the  greater  and 
lesser  sacro-sciatic  ligaments.  These  structures  are  also  divided  close 
to  the  edge  of  the  sacrum. 

In  dividing  the  gluteus  maximus  muscle  branches  of  the  gluteal 
artery  are  cut;  these  may  be  clamped  and  tied.  Penetrating  through 
the  fat  in  the  ischio-rectal  fossa  the  coccygeus,  which  is  attached  to 
the  border  of  the  coccyx  and  sacrum,  and  the  levator  ani,  which  is 
attached  to  the  coccyx  near  its  tip,  are  exposed.  These  muscles  are 
covered  over  by  a  thin  fascia — the  anal;  they  are  divided  with  the 
knife  close  to  the  edge  of  the  sacrum  and  coccyx.    The  soft  parts  are 


OPERATIONS  UPON  THE  RECTUM. 


355 


then  separated  with  a  periosteum  elevator  from  the  posterior  surface 
and  right  border  of  the  coccyx,  and  while  it  is  forced  forward  the 
sacro-coccygeal  joint  is  opened  from  behind  and  the  bone  seized  with 
the  bone  forceps  and  extirpated.  The  sphincter  ani  is  cut  away  from 
the  tip  of  the  coccyx  close  to  the  bone.  If  the  arteria  sacra  media, 
which  descends  in  front  of  the  sacrum,  is  injured,  it  may  be  clamped 
and  tied. 

The  levator  ani  and  coccygeus  muscles  having  been  already  di- 
vided, the  operator  now  penetrates  through  the  loose,  fatty  tissue 
which  lies  behind  the  rectum  with  the  fingers  so  as  to  expose  the 
posterior  surface  of  the  rectum.  The  rectum  moves  with  respiration, 
and  shows  an  impulse  if  the  patient  coughs  or  strains. 


Fig.  144. — Back  Part  of  Ilium  and  Sacrum.  Coccyx  removed.  A,  A,  usual 
line  of  section  through  sacrum;  A,  B,  line  cf  section  to  remove  all  of  lower 
part  of  sacrum;  SI,  lower  end  of  sacro-iliac  articulation;  1,  2,  3,  4,  poste- 
rior sacral  foramina. 


In  many  cases  one  may  proceed  at  once  with  the  second  step  of 
the  operation:  the  extirpation  of  the  diseased  part  of  the  rectum. 
At  times,  however,  the  space  is  not  sufficiently  ample,  especially  if 
the  tumor  is  adherent  and  cannot  be  readily  drawn  down  into  the 
wound,  or  if  the  space  between  the  border  of  the  sacrum  and  the 
ascending  ramus  of  the  ischium  (spatium  sacro-ischiadicum,  Kraske) 
is  unusually  narrow.  In  these  cases  in  order  to  obtain  more  room 
it  will  be  necessary  to  resect  a  portion  of  the  sacrum.  This  may  be 
done  with  the  chisel,  bone  forceps,  or  saw.  The  soft  parts  are  sepa- 
rated from  the  lower  part  of  the  left  half  of  the  posterior  surface  of 
the  sacrum  with  the  periosteum  elevator,  and  that  portion  of  the 


35G  RECTUM. 

sacrum  then  resected  which  lies  below  a  line  that  commences  at  the 
left  border  of  the  bone,  just  below  the  level  of  the  third  posterior 
sacral  foramen;  curving  downward  and  inward  toward  the  middle 
line  and  passing  between  the  third  and  fourth  posterior  sacral  fo- 
ramina, this  line  terminates  at  the  middle  of  the  lower  border  of  the 
sacrum.  If  necessary  to  get  still  more  room  the  line  of  section 
through  the  sacrum  may  be  carried  straight  across  the  sacrum,  just 
below  the  third  posterior  sacral  foramina  from  the  left  to  the  right 
border  of  the  bone,  thus  removing  all  of  the  sacrum  below  the  third 
sacral  foramina.  The  line  of  section  through  the  sacrum  may  ter- 
minate at  any  point  between  those  described  above.  The  guide  to 
the  location  of  the  third  sacral  foramen  is  the  lower  end  of  the  sacro- 
iliac articulation.  The  lower  end  of  the  sacro-iliac  articulation  lies 
just  above  the  lower  margin  of  the  third  posterior  sacral  foramen. 

In  making  the  resection  of  the  sacrum  it  is  unwise  to  go  above 
the  lower  border  of  the  third  posterior  sacral  foramen  on  account 
of  the  important  structures  which  emerge  from  the  first,  second,  and 
third  anterior  sacral  foramina  (sacral  plexus).  Through  the  fourth 
anterior  sacral  foramen  branches  emerge  which  are  distributed  to 
the  bladder  and  the  rectum.  If  these  branches  are  damaged  some 
disturbance  of  the  function  of  these  organs  will  follow,  but  this  is 
only  temporary,  control  being  rapidly  regained.  If  the  left  half  only 
of  the  lower  portion  of  the  sacrum  is  removed,  this  disturbance  will 
be  much  less  marked. 

Kesection  of  the  Diseased  Portion  of  the  Bowel  (the 
Anal  Portion  being  Free  from  Disease). — With  the  fingers  the 
diseased  portion  of  the  rectum  is  freed  upon  its  posterior  aspect 
and  upon  the  sides  from  the  loose  fat  and  connective  tissue  that  sur- 
round it.  It  is  then  likewise  freed  upon  its  anterior  aspect.  As  we 
proceed  with  the  isolation  of  the  rectum,  it  may  be  necessary  to  cut 
some  connective  tissue  bands  with  the  scissors.  All  blood-vessels 
are  clamped  and  tied  as  they  are  divided.  During  this  step  of  the 
operation  one  should  take  care  not  to  open  into  the  rectum.  When 
the  diseased  part  of  the  rectum  has  been  thus  freed  all  around,  a 
heavy  silk  ligature  or  strip  of  gauze  is  tied  tightly  around  it,  just 
below  the  lower  limits  of  the  disease,  and  through  the  anus,  the  lower 
part  of  the  bowel,  after  being  again  thoroughly  irrigated,  is  packed 
with  gauze.  The  bowel  is  then  divided  transversely  below  the  liga- 
ture with  the  scissors  or  knife,  thus  cutting  the  diseased  portion  away 
from  the  lower  healthy  (anal)  segment  of  the  bowel.    The  wound  is 


OPERATIONS  UPON  THE  RECTUM. 


357 


not  soiled,  because  the  diseased  segment  is  shut  off  by  the  ligature 
which  has  been  applied  about  it,  and  the  lower  anal  segment,  besides 
having  been  thoroughly  sterilized,  is  packed  with  gauze. 


Fig.  145. — Resection  of  Rectum  (Kraske).  Rectum  exposed  and  ligature 
passed  around  it  just  below  the  diseased  portion  (*)  that  is  to  be  excised. 
A,  line  of  incision  through  rectum. 


Fig.  146.— Resection  of  Rectum  (Kraske).  Diseased  portion  (*)  cut  away 
from  the  healthy  lower,  anal  portion.  A  ligature  has  been  placed  about  the 
rectum  just  above  the  diseased  portion.  B,  line  of  section  that  separates  the 
diseased  portion  from  the  healthy  upper  portion. 


The  diseased  portion  of  the  gut  is  now  seized,  and,  while  trac- 
tion is  made,  it  is  gradually  dissected  out  of  its  bed  of  fat  and  con- 
nective tissue,  being  thoroughly  isolated  upon  all  sides,  so  that  it 


358  RECTUM. 

can  be  pulled  down  as  far  as  necessary.  This  is  accomplished  largely 
by  blunt  dissection  with  the  fingers.  Just  beyond  the  upper  limits 
of  the  disease,  when  this  becomes  feasible,  a  second  ligature  is  thrown 
around  the  rectum  and  tied,  and  thus  the  contents  of  the  diseased  seg- 
ment are  imprisoned  within  that  portion  of  the  bowel  which  is  to  be 
resected.  The  rectum  is  now  drawn  out  of  the  wound  as  far  as  possible, 
and  placed  upon  sterile,  gauze  pads,  and  the  diseased  part  cut  away 
from  the  upper  healthy  portion  of  the  bowel.  Before  this  is  done  an 
assistant  grasps  and  compresses  the  lower  part  of  the  upper  healthy 
segment  of  the  bowel,  beyond  the  intended  line  of  section,  between  the 
fingers,  so  that,  when  the  diseased  portion  is  cut  away,  the  end  of 
the  bowel  cannot  escape,  and  also  to  prevent  the  escape  of  its  con- 
tents. Should  there,  however,  accidentally  be  any  leakage,  the  wound 
is  protected  by  the  compress  which  has  been  arranged  beneath  the 
bowel  before  the  section  is  made. 

The  diseased  portion  having  been  thus  excised,  the  proximal,  or 
upper,  segment  of  the  bowel  is  immediately  packed  with  gauze. 
Bleeding  from  the  edge  of  the  bowel  may  be  checked  by  clamps  and, 
if  necessary,  ligatures. 

In  freeing  the  rectum  upon  its  anterior  aspect,  one  has  to  deal 
with  the  pouch  of  peritoneum  which  dips  down  upon  its  front  wall, 
between  it  and  the  uterus  and  vagina  in  the  female  and  the  bladder 
in  the  male.  One  should  recognize  this  pouch,  as  it  may  be  necessary 
to  open  it,  and,  indeed,  this  is  probably  desirable  in  all  cases,  as  it 
enables  one  to  bring  down  the  upper  part  of  the  bowel  with  more 
ease.  After  an  opening  has  been  made  into  this  pouch,  it  may  be 
enlarged  by  cutting  with  the  scissors,  upon  either  side,  close  to  the 
wall  of  the  rectum;  through  the  opening  thus  made  two  fingers  may 
be  introduced  and  the  bowel  drawn  down;  after  it  has  been  pulled 
down  sufficiently,  one  may  sew  the  edge  of  the  opening  in  the  peri- 
toneum to  the  peritoneal  layer  that  covers  the  bowel,  upon  either 
side,  with  several  catgut  sutures;  the  anterior  portion,  however, 
should  be  left  open  for  drainage.  Kraske  advises  against  closing  this 
opening  in  the  peritoneal  pouch  even  in  part.  He  says  that  it  should 
be  loosely  packed  with  strip  gauze,  surrounding  the  rectum  in  front, 
upon  the  sides,  and  behind,  and  reaching  well  up  into  the  peritoneal 
cavity;  the  extremities  of  the  gauze  strips  are  allowed  to  emerge 
through  the  upper  part  of  the  skin  incision,  and  should  be  marked 
for  identification,  so  that  they  may  be  removed  after  five  or  six  days. 
If  this  fold  of  peritoneum  is  involved  in  the  disease,  it  may  be  oblit- 


OPERATIONS  UPON  THE  RECTUM.  359 

erated  by  its  opposing  surfaces  having  become  agglutinated,  or  the 
growth  may  have  extended  still  farther  so  as  to  involve  the  uterus  or 
bladder.  This  will  add  to  the  difficulty  of  the  operation;  but  some 
surgeons  do  not  consider  it  a  counter-indication  to  the  continuance 
of  the  operation,  because,  if  necessary,  the  parts  of  these  organs  that 
are  involved  may  be  resected. 

If  the  peritoneal  fold  is  not  involved  in  the  disease  it  can  usually 
be  peeled  away  from  the  front  wall  of  the  rectum  with  the  finger, 
and  in  this  case  one  may  be  able  to  complete  the  operation  without 
opening  into  the  peritoneal  cavity. 

Diseased  lymphatic  nodes  located  behind  the  rectum,  between 
it  and  the  sacrum,  should  also  be  enucleated.  There  may  be  con- 
siderable bleeding  caused  by  separating  the  rectum  upon  its  posterior 
aspect  and  sides  from  branches  of  the  superior  hemorrhoidal;  they 
should  be  clamped  and  ligated. 

Sutttke  of  the  Ends  of  the  Bowel. — The  upper  segment 
should  be  sutured  to  the  lower  (anal  portion),  and  this  union  may  be 
either  complete  or  partial. 

Complete  Union,  the  Ideal  Method. — During  the  application  of 
the  sutures  care  should  be  taken  that  no  fasces  soil  the  suture  line; 
a  wad  of  gauze  packed  into  the  upper,  central,  segment  of  the  bowel 
prevents  this.  There  should  be  no  tension  on  the  upper  segment — 
no  tendency  for  it  to  draw  up  into  the  abdomen  away  from  the  anal 
portion.  Proper  isolation  of  the  rectum  and  the  opening  of  the  peri- 
toneal pouch  will  obviate  this. 

One  may  further  fix  the  upper,  central,  segment  of  the  bowel  in 
the  wound  by  several  non-perforating  sutures.  For  uniting  the  ends 
of  the  bowel  fine  silk  sutures  should  be  used.  One  may  commence 
the  suture  in  the  middle  line  anteriorly  and  work  around  upon  either 
side  toward  the  back.  The  sutures  should  be  introduced  from  the 
inner  surface  of  the  bowel  and  tied  so  that  the  knots  are  within  the 
lumen  of  the  bowel — they  should  be  interrupted,  and  each  should 
include  the  whole  thickness  of  the  wall  of  the  gut,  and  be  placed 
about  1/2  cm.  distant  from  each  other.  Those  sutures  which  are 
introduced  last,  and  which  join  the  two  segments  of  the  bowel  poste- 
riorly, must  be  introduced  from  the  outer  surface,  and  do  not  pene- 
trate the  whole  thickness  of  the  wall  of  the  bowel,  but  simply  include 
the  outer  coats.  When  these  latter  sutures  are  tied,  the  knots  will 
be  found  upon  the  outer  aspect  of  the  bowel.  Before  closing  this 
posterior  portion  of  the  wound  Hochenegg  advises  the  introduction 


5G0 


RECTUM. 


of  a  rubber  tube  surrounded  by  gauze  from  the  anus  well  up  into 
the  bowel  beyond  the  suture  line.  This  prevents  soiling  of  the  suture 
line  and  also  permits  the  passage  of  gas  and  fluid  fasces  during  the 
few  days  immediately  following  the  operation.  A  strip  of  gauze 
should  be  introduced  into  the  wound,  so  as  to  lead  from  the  suture 
line  upon  each  side  of  the  bowel  out  through  the  incision,  for  the 
purpose  of  providing  drainage  for  this  part,  in  the  event  of  the 
sutures  giving  way.  There  is  some  danger  in  complete  closure  of 
the  bowel.  The  sutures  may  tear  through  and  allow  the  contents 
of  the  bowel  to  escape  into  the  wound,  especially  if  the  obstruction 


Fig.  147. — Resection  of  Rectum  (Kraxlce).  Diseased  port'on  has  been  ex- 
cised and  the  healthy  upper  and  lower  portions  have  been  partially  united 
with  interrupted  sutures  that  penetrate  the  entire  thickness  of  the  wall  of 
the  bowel. 


offered  by  the  disease  had  prevented  the  complete  evacuation  of  tbe 
bowel  before  the  operation.  Masses  of  fasces  come  down  and  put  a 
strain  upon  the  stitches;  if  this  accident  occurs,  the  wound  becomes 
infected,  and  we  may  get,  as  a  result,  a  fatal  peritonitis. 

Union  most  often  fails  in  the  posterior  part  of  the  suture  line 
in  the  bowel;  this  is  due  probably  to  the  damage  done  to  the  vessels 
which  supply  the  bowel,  in  isolating  it.  Such  a  break  of  the  suture 
line,  however,  usually  does  no  harm  if  proper  drainage  of  the  wound 
has  been  provided,  and  usually  the  resulting  faecal  fistula  closes  spon- 
taneously, or  may  be  closed  by  use  of  adhesive  plaster  strips  in  dress- 
ing or  by  a  subsequent  operation. 


OPERATIONS  UPON  THE  RECTUM.  361 

Partial  Union. — Instead  of  making  a  complete  union  we  may 
join  the  ends  of  the  segment  of  the  bowel  only  anteriorly  and  upon 
the  sides,  leaving  the  posterior  part  of  the  wound  open.  The  upper 
segment  of  the  bowel  is  then  fixed  in  the  wound  to  prevent  its  re- 
traction. In  this  case  we  wait  for  the  faecal  fistula  that  results  to 
close  spontaneously,  or  else  we  accomplish  this  by  a  subsequent 
operation. 

However  the  ends  of  the  bowel  are  treated,  the  wound  should 
be  well  packed  with  iodoform  gauze — not  too  tight,  but  reaching 
well  down  to  the  bottom  of  all  parts  of  the  wound.  This  packing  is 
allowed  to  remain  until  it  becomes  loosened, — usually  for  about  one 
week, — when  the  wound  is  again  dressed  and  repacked.  The  incision 
in  the  skin  is  partly  closed. 

For  Amputatio  Eecti  (the  Anal  Portion  of  the  Bowel  being 
Involved  in  the  Disease).— If  it  is  desired  to  remove  the  lower 
(anal)  portion  of  the  bowel,  together  with  the  rest  of  the  rectum,  the 
skin  incision  should  be  prolonged  from  the  tip  of  the  coccyx,  so  as  to 
encircle  the  anus.  After  the  coccyx  and  part  of  the  sacrum  have  been 
resected  as  described  above,  the  whole  length  of  the  bowel,  including 
the  anal  portion,  is  isolated,  beginning  below  at  the  anus  and  work- 
ing upward.  Upon  either  side  near  the  anus  the  attachment  of  the 
levator  ani  is  separated  from  the  rectum  with  the  scissors,  working 
close  to  the  wall  of  the  rectum.  At  times,  some  difficulty  in  sepa- 
rating the  rectum  from  the  prostate  or  the  vagina  is  experienced. 
A  sound  may  be  introduced  into  the  bladder,  and  this  part  of  the 
operation  done  in  the  perineal  position.  This  change  of  position, 
however,  is  probably  unnecessary.  When  the  bowel  has  been  isolated 
to  a  point  beyond  the  upper  limits  of  the  disease,  a  ligature  may  be 
thrown  around  the  rectum  and  the  diseased  portion  cut  away.  The 
end  of  the  proximal  (upper)  part  of  the  bowel  into  which  a  strip  of 
gauze  has  been  packed  is  then  sewed  to  the  margins  of  the  skin  in 
the  upper  part  of  the  incision  close  to  the  edge  of  the  sacrum  with 
interrupted  silk  sutures.  The  wound  is  then  packed  carefully  about 
the  bowel,  above  and  below,  and  the  skin  incision  partly  closed  with 
several  silk  sutures.  The  bowel  may  be  twisted  through  a  quarter  of 
a  circle  before  uniting  it  to  the  margin  of  the  skin,  with  the  idea  of 
making  the  artificial  anus  more  retentive. 


PART  VII. 

HERNIA,  SPERMATIC  CORD,  TESTES,  ETC. 


The  Surgical  Anatomy  of  the  Groin. — The  groin  may  be  divided 
into  the  inguinal  and  femoral  regions.  These  parts  may  be  consid- 
ered more  or  less  together,  on  account  of  the  close  relationship  that 
exists  between  them. 

The  inguinal  region  corresponds  to  that  part  of  the  anterior 
abdominal  wall  which  lies  just  above  Poupart's  ligament,  and  is 
traversed  by  a  canal  for  the  passage  of  the  spermatic  cord,  in  the 
male,  and  the  round  ligament,  in  the  female.  By  invaginating  the 
integument  of  the  scrotum,  the  finger  may  be  introduced  into  this 
canal. 

The  femoral  region  corresponds  to  the  upper  anterior  part  of 
the  thigh — the  area  immediately  below  Poupart's  ligament.  Under- 
neath Poupart's  ligament,  between  it  and  the  pubic  bone,  there  is  a 
space  through  which  the  ilio-psoas  muscle  and  anterior  crural  nerve, 
and  the  femoral  vessels,  etc.,  pass  from  the  abdomen  into  the  thigh. 

The  Supekficial  Layer  of  the  Superficial  Fascia.  —  Be- 
neath the  skin  of  the  groin  there  is  a  loose  connective  tissue  layer 
which  contains  a  varying  amount  of  fat,  and  in  which  the  blood- 
vessels, nerves,  lymphatic  glands,  etc.,  are  located.  This  layer  is 
called  the  superficial  layer  of  the  superficial  fascia.  In  some  subjects 
it  is  very  thick.  It  is  continuous  with  the  general  fatty  layer  of  the 
body.  In  the  male  it  is  continued  on  to  the  penis,  where  it  is  thin 
and  loose,  forming  one  of  the  coats  of  that  organ,  and  in  the  scrotum 
is  continued  into  the  dartos.  From  the  scrotum  it  may  be  traced 
back  into  the  perineum,  where  it  is  known  as  the  superficial  layer 
of  the  superficial  perineal  fascia.  In  the  female  it  is  continuous  with 
the  fatty  layer  of  the  labia  majora,  each  one  of  which  corresponds 
to  one-half  of  the  scrotum.  The  vessels  which  are  found  in  this 
layer,  and  which  may  be  cut  in  making  the  skin  incisions  in  operating 
upon  these  parts,  are  the  superficial  epigastric,  superficial  circumflex 
iliac,  and  superficial  external  pudic  arteries,  together  with  their  cor- 
responding veins. 
(362) 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  363 

The  Lymphatic  Glands. — The  lymphatic  glands  of  this  region 
are  arranged  in  two  groups:  one  group,  the  inguinal,  is  spread  along 
Poupart's  ligament,  and  drains  the  external  genitals,  scrotum,  penis, 
etc.;  the  other  group  lies  along  the  saphenous  vein,  and  in  and  about 
the  saphenous  opening.  These  drain  the  lower  limb.  In  extirpating 
the  inguinal  group  of  glands  there  is  but  little  hemorrhage,  but  it 
is  necessary  to  avoid  the  spermatic  cord.  In  extirpating  the  lower, 
femoral,  group  there  may  be  considerable  hemorrhage,  and  one  must 
avoid  injury  to  the  internal  saphenous  vein  and  to  the  femoral  vein, 
especially  when  excising  those  glands  that  are  lodged  in  the  saphe- 
nous opening. 

The  Deep  Latek  of  the  Superficial  Fascia. — After  the  fatty 
layer  has  been  removed  from  this  region  the  deep  layer  of  the  super- 
ficial fascia  is  exposed.  This  fascia  is  thin,  and  covers  the  aponeu- 
rosis of  the  external  oblique  muscle  in  the  inguinal  region,  and  the 
fascia  lata  in  the  femoral  region.  It  is  adherent,  in  the  middle  line, 
to  the  linea  alba,  and,  just  below  Poupart's  ligament,  to  the  fascia 
lata.  In  the  male  it  forms  one  of  the  coverings  of  the  penis,  and  is 
continued  into  the  scrotum,  where  it  forms  the  dartos,  and  backward 
beyond  the  scrotum,  into  the  perineum,  where  it  forms  the  deep  layer 
of  the  superficial  perineal  fascia.  In  the  perineum  it  is  attached 
laterally  to  the  rami  of  the  pubes,  and  behind  to  the  transverse  peri- 
neal raphe.  In  the  female  this  layer  is  continued  into  the  labia 
majora.  This  fascia  is  firmly  attached  to  the  margins,  or  pillars,  of 
the  external  ring,  and  is  known  as  the  external  spermatic  fascia. 
Entrance  into  the  inguinal  canal  cannot  be  effected  until  this  layer 
of  fascia  has  been  incised.  From  the  margins  of  the  ring  this  layer 
of  fascia  is  continued  downward,  surrounding  the  cord  and  forming 
one  of  its  investments,  and  below,  as  already  mentioned,  it  is  found 
in  the  scrotum  as  the  dartos.  Below  Poupart's  ligament,  in  the 
femoral  region,  this  layer  of  fascia  is  firmly  adherent  to  the  margins 
of  the  saphenous  opening  in  the  fascia  lata,  where  it  is  perforated 
by  numerous  vessels  and  lymphatics,  and  is  called  the  cribriform 
fascia.  From  this  point  on,  the  inguinal  and  femoral  regions  may  be 
studied  separately. 

The  Inguinal  Kegion. — The  inguinal  region  is  the  site  of  in- 
guinal hernia.  After  removing  the  deep  layer  of  the  superficial 
fascia  from  the  inguinal  region  (including  the  margins  of  the  exter- 
nal ring),  we  expose  the  aponeurosis  of  the  external  oblique  and  the 
external  inguinal  ring,  into  which  the  finger  may  be  introduced,  and 


36-i  HERNIA,  ETC. 

from  which  the  spermatic  cord  (the  round  ligament  in  the  female) 
is  seen  to  emerge. 

The  aponeurosis  of  the  external  oblique  is  the  strong,  smooth, 
glistening,  bluish-white,  fibrous  expansion  of  the  external  oblique 
muscle.  Its  fibers  have  an  oblique  direction  downward  and  inward 
toward  the  middle  line,  and  join  with  each  other  in  the  linea  alba. 
The  lower  fibers  of  the  aponeurosis  of  the  external  oblique  are  col- 
lected into  a  thick  bundle  to  form  Poupart's  ligament. 

Poupart's  ligament  is  a  strong,  fibrous  band  which  extends  from 
the  anterior  superior  spinous  process  of  the  ilium  downward  and 
inward  to  the  spine  of  the  pubes.  Both  these  bony  processes  are 
easily  made  out;  the  latter,  the  spine  of  the  pubes,  is  readily  felt 
beneath  the  soft  parts  upon  the  upper  border  of  the  pubic  bone, 
about  three-fourths  inch  from  the  symphysis.  The  fibers  of  the 
aponeurosis  of  the  external  oblique  immediately  above  Poupari's 
ligament  pass  inward  toward  the  middle  line,  interlacing  with  those 
from  the  opposite  side,  and  are  attached  to  the  symphysis,  and  there 
is  thus  left  a  triangular  opening  in  the  aponeurosis,  which  is  called 
the  external  inguinal  ring.  This  so-called  ring  is  simply  a  split  in 
the  aponeurosis  of  the  external  oblique.  Its  outer,  or  lower,  border, 
or  pillar,  is  formed  by  Poupart's  ligament;  its  inner,  or  upper, 
border,  or  pillar,  is  formed  by  those  fibers  of  the  aponeurosis  of  the 
external  oblique  which  are  attached  in  the  middle  line  to  the  sym- 
physis, interlacing  with  those  of  the  opposite  side.  The  apex  of  this 
opening  is  directed  upward  and  outward;  its  base  corresponds  to  the 
crest,  or  upper  surface,  of  the  body  of  the  pubic  bone,  that  portion 
of  the  bone  which  is  included  between  the  pubic  spine,  to  which  Pou- 
part's ligament  is  attached,  and  the  symplrysis.  Various  stay  fibers 
are  seen  in  the  aponeurosis,  passing  from  below  upward  and  imward, 
near  the  apex  of  the  external  ring.  These  serve  to  bind  the  pillars 
of  the  ring  firmly  together,  and  are  called  the  intercolumnar  fibers. 

The  spermatic  cord  (round  ligament  in  the  female)  is  seen 
emerging  from  the  external  ring,  and  a  director  may  be  introduced 
through  the  ring  upward  and  outward  into  the  inguinal  canal.  From 
the  inner  end  of  Poupart's  ligament — i.e..,  from  the  external  pillar 
of  the  ring — a  triangular  sheet  of  fibers  is  given  off,  which  is  reflected 
upward  and  inward  toward  the  middle  line,  and  is  continued  into  the 
anterior  layer  of  the  sheath  of  the  rectus  muscle.  This  is  called  the 
triangular  ligament,  or  Colles's  ligament,  and  is  situated  behind  the 
inner  end  of  the  external  ring,  and  in  front  of  the  conjoined  tendon, 


Fig.  1J8.— Inguinal  and  "Femoral  Regions.  FP,  edge  of  falciform  process;  FV,  femoral  vein; 
LA,  lineaalba;  LS,  linea  semilunaris;  P,  Poupart's  ligament.  The  external  inguinal  ring  is  shown 
with  the  spermatic  cord  emerging.  The  fibers  crossing  the  upper  outer  angle  of  the  ring  are  known 
as  the  intercolumnar  fibers. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  365 

and  serves  to  strengthen  this  part.  If  we  examine  still  further  this 
inner  end  of  Poupart's  ligament, — i.e.,  the  external  pillar  of  the 
ring, — we  find  given  off  from  its  lower  border,  just  before  its  attach- 
ment to  the  pubic  spine,  a  strong  triangular  band,  which  is  attached 
to  the  ilio-pectineal  line,  a  prominent  ridge  upon  the  upper  surface 
of  the  pubic  bone,  which  is  continued  outward  and  backward  from 
the  pubic  spine  to  the  edge,  or  brim,  of  the  true  pelvis.  This  band 
in  known  as  Gimbernat's  ligament.  It  presents  an  outer,  sharp, 
curved  edge,  and  is  of  much  anatomical  interest  in  the  study  of 
femoral  hernia. 

The  Inguinal  Canal. — The  inguinal  canal  is  an  oblique  slit  in 
the  abdominal  wall,  and,  under  ordinary  circumstances,  the  greater 
the  intra-abdominal  pressure,  the  tighter  its  closure.  It  is  from  4 
to  5  cm.  (one  and  one-half  inches)  long,  and  lies  above  and  parallel 
with  Poupart's  ligament.  It  terminates  beneath  the  integument  at 
the  external  inguinal  ring,  a  triangular  opening  in  the  aponeurosis  of 
the  external  oblique,  which  is  located  just  above  the  crest  of  -the 
pubes. 

If  we  introduce  a  director  through  the  external  ring  into  the 
inguinal  canal,  and  pass  it  in  a  direction  upward  and  outward  under- 
neath the  aponeurosis  of  the  external  oblique,  to  a  point  about  half 
an  inch  above  the  middle  of  Poupart's  ligament, — i.e.,  the  location  of 
the  internal  ring, — and  then  split  the  aponeurosis  upon  this,  we 
open  up  the  inguinal  canal  and  expose  its  contents:  the  spermatic 
cord,  in  the  male;  the  round  ligament,  in  the  female.  The  cut  edges 
of  the  aponeurosis  should  be  seized  with  artery  forceps  and  separated 
freely  from  the  underlying  parts  with  the  finger.  The  spermatic 
cord  is  a  structure  as  big  around  as  the  little  finger.  It  is  made  up 
of  the  vas  deferens,  which  is  the  efferent  duct  of  the  testicle;  the 
artery  of  the  vas  deferens  and  the  cremasteric  artery,  and  their 
corresponding  veins;  the  spermatic  artery,  and  the  pampiniform 
venous  plexus.  As  these  structures  traverse  the  inguinal  canal  they 
are  all  bound  together  into  a  single  rounded  cord  by  a  strong  sheath 
of  fascia,  the  infundibular  process  of  the  transversalis  fascia.  De- 
scending upon  the  cord  are  also  seen  the  fibers  of  the  cremaster 
muscle,  which  are  derived  from  the  lower  edge  of  the  internal  oblique 
in  the  descent  of  the  testes.  The  cord  is  also  accompanied,  in  its 
course  through  the  inguinal  canal,  by  the  genital  branch  of  the 
genito-crural  nerve  and  the  inguinal  branch  of  the  ilio-inguinal 
nerve. 


366  HERNIA,  ETC. 

After  the  inguinal  canal  has  heen  opened  hy  splitting  the  apo- 
neurosis of  the  external  oblique,  the  free,  curved,  fleshy  edge  of  the 
internal  oblique  is  exposed  to  view.  This  muscle,  the  part  seen  here, 
arises  from  the  outer  half  of  Poupart's  ligament.  If  the  edge  of  this 
muscle  is  raised  and  drawn  upward  and  outward  for  a  short  distance, 
or  incised,  we  expose  the  transversalis  muscle,  which  lies  beneath  the 
internal  oblique.  That  portion  of  the  transversalis  which  is  thus 
exposed  arises  from  the  outer  third  of  Poupart's  ligament,  and  is 
covered  by  the  internal  oblique,  and  is  not  seen  until  the  edge  of 
this  latter  muscle  has  been  drawn  aside. 

Toward  the  outer  part  of  the  inguinal  canal  these  two  muscles, 
where  they  arise  from  Poupart's  ligament,  are  situated  for  a  short 
distance  in  front  of  the  spermatic  cord.  They  then  arch  inward 
above  the  cord,  and,  joining  with  each  other,  become  tendinous,  and, 
as  the  conjoined  tendon,  descend  behind  the  cord,  to  be  attached  to 
the  upper  surface  of  the  pubic  bone;  i.e.,  the  crest  and  the  pectin- 
eal line.  The  conjoined  tendon,  at  its  attachment  to  the  pubic 
bone,  is  placed  behind  the  external  ring,  and  participates  in  the 
formation  of  the  inner  part  of  the  posterior  wall  of  the  inguinal 
canal.  It  is  important  to  note  that  that  portion  of  the  posterior 
wall  of  the  inguinal  canal  which  is  included  between  the  arching 
free  edge  of  the  internal  oblique  muscle  above  and  Poupart's  liga- 
ment below  is  formed  by  the  transversalis  fascia  only.  This  fascia 
is  a  fibrous  layer  which  lines  the  whole  inner  surface  of  the  abdomen, 
including  the  posterior  surface  of  the  anterior  abdominal  wall,  and 
it  is  here  exposed  to  view  where  the  muscle  is  deficient;  i.e.,  between 
The  edge  of  the  internal  oblique  muscle  above  and  Poupart's  ligament 
below.  Through  the  outer  part  of  the  posterior  wall  of  the  inguinal 
canal  the  several  structures  which  go  to  make  up  the  spermatic  cord 
(round  ligament  in  the  female)  pass  forward  into  the  inguinal 
canal,  being  provided  with  a  strong,  fibrous  sheath,  which  is  known 
as  the  infundibular  process,  by  the  fascia  transversalis.  This  sheath 
incloses  the  several  elements  of  which  the  cord  is  composed,  and 
serves  to  bind  them  together  into  a  single  bundle,  which  traverses 
the  inguinal  canal  and  emerges  at  the  external  inguinal  ring.  The 
point  at  which  the  structures  which  constitute  the  spermatic  cord 
pass  forward  into  the  inguinal  canal  is  the  site  of  the  internal  ingui- 
nal ring.  The  internal  ring  is  an  opening  in  the  transversalis  fascia, 
which  is  located  half  an  inch  above  the  middle  of  Poupart's  liga- 
ment.    The  inguinal  canal  proper  has  no  internal  opening;    i.e.,  it 


Fig.  U9. — The  Inguinal  Canal.  The  canal  has  been  laid  open  by  splitting-  the  aponeurosis 
of  the  external  oblique  {A),  which  is  grasped,  with  the  artery  forceps  and  drawn  upward; 
CT,  edge  of  the  internal  oblique  muscle  (conjoined  tendon);  E,  dotted  line  represents  the  course 
of  the  deep  epigastric  artery,  which  is  located  beneath  the  transversalis  fascia ;  P,  Poupart's 
ligament;  TF,  transversalis  fascia,  which  forms  the  posterior  wall  of  the  inguinal  canal; 
TL,  triangular  ligament,  which  is  given  off  from  the  inner  end  of  Poupart's. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  367 

does  not  communicate  with  the  abdominal  cavity.  The  internal  in- 
guinal ring  is  really  the  mouth  of  the  infundibular  process,  which 
is,  in  reality,  the  sheath  that  is  provided  to  the  spermatic  cord  from 
the  transversalis  fascia. 

The  infundibular  process  is  a  glove-finger-like  diverticulum,  or 
pocket,  which  is  derived  from  the  fascia  transversalis,  being  pro- 
longed downward  into  the  bottom  of  the  scrotal  sac,  and,  through 
this,  the  testicle,  drawing  the  vas  deferens,  etc.,  after  it,  descends 
in  its  journey  from  the  abdomen  into  the  scrotum.  After  the  testis 
has  reached  the  bottom  of  the  scrotal  sac,  the  upper  part  of  this 
infundibular  process — i.e.,  the  part  which  corresponds  to  the  cord 
— contracts  and  shrinks  so  closely  around  the  structures  which  make 
up  the  cord,  and  which  are  contained  within  it,  that  its  cavity  is, 
in  this  way,  entirely  obliterated,  and  the  shrunken  infundibular 
process  remains  permanently  as  the  proper  fibrous  sheath  of  the 
spermatic  cord. 

The  lower  part,  however,  of  the  infundibular  process  remains 
permanently  unchanged  as  one  of  the  layers  of  the  scrotum. 

The  contraction  of  the  infundibular  process  about  the  upper 
part  of  the  cord  may  be  incomplete,  and  there  may  be  thus  left  a 
space  within  the  sheath  of  the  cord  (infundibular  process),  into 
which  the  point  of  the  finger  may  be  insinuated  from  within  the 
abdomen.  The  finger  under  these  circumstances  does  not  enter  the 
inguinal  canal,  but  passes  through  the  internal  ring  into  the  proper 
sheath  of  the  spermatic  cord.  The  mouth  of  the  infundibular  proc- 
ess, the  "internal  ring/'  may  be  best  studied  from  within  the  ab- 
domen, after  the  peritoneum,  which  lines  this  portion  of  the  ab- 
dominal wall,  has  been  stripped  away. 

Beneath  the  transversalis  fascia — i.e.,  the  posterior  wall  of  the 
inguinal  canal- — -is  found  the  parietal  layer  of  the  peritoneum,  with 
an  intervening  stratum  of  loose  connective  tissue,  containing  fat,  be- 
tween it  and  the  transversalis  fascia;  this  is  the  so-called  subperi- 
toneal connective  tissue  layer.  The  layer  of  peritoneum  which  lies 
behind,  or  rather  beneath,  the  posterior  wall  of  the  inguinal  canal 
presents  no  opening  whatever.  Within  the  abdomen,  about  the 
mouth  of  the  infundibular  process,  "internal  ring/'  the  parietal  peri- 
toneum is  adherent  to  the  transversalis  fascia,  and  may  show  a  slight 
bulging  into  the  neck  of  the  infundibular  process  (sheath  of  the 
cord).  * 

In  the  study  of  these  parts  the  deep  epigastric  artery  plays 


368  HERNIA,  ETC. 

an  important  role.  This  artery  may  be  seen,  or  its  pulsation  felt, 
as  it  lies  beneath  the  transversalis  fascia  in  the  subperitoneal  con- 
nective tissue  between  the  transversalis  fascia  and  the  peritoneum. 
The  artery  is  accompanied  by  one  or  two  veins.  It  arises  from  the 
external  iliac  (femoral)  just  before  this  vessel  passes  out  of  the  ab- 
domen under  Poupart's  ligament,  and  ascends  obliquely  upward  and 
inward  toward  the  umbilicus  to  reach  the  outer  border  of  the  rectus 
muscle.  It  passes  across  the  posterior  wall  of  the  inguinal  canal 
about  the  middle,  and  so  divides  it  into  two  parts,  an  outer  and  an 
inner.  The  outer  part  of  the  posterior  wall  of  the  inguinal  canal, 
that  part  which  lies  external  to  the  deep  epigastric  artery,  is  formed 
by  the  transversalis  fascia  and  the  underlying  peritoneum,  and  pre- 
sents the  opening  through  which  the  structures  that  form  the 
spermatic  cord  (round  ligament)  leave  the  abdomen,  the  internal 
ring.  The  presence  of  this  orifice  tends  to  weaken  this  outer  part 
of  the  posterior  wall  of  the  inguinal  canal.  The  inner  portion  of  the 
posterior  wall  of  the  inguinal  canal,  that  part  which  lies  internal 
to  the  deep  epigastric  artery,  is  strengthened,  in  part,  by  several 
additional  layers.  From  before  backward  this  part  of  the  posterior 
wall  of  the  inguinal  canal  is  formed  of  the  triangular  ligament, 
conjoined  tendon,  transversalis  fascia,  and  parietal  peritoneum. 
This  inner  portion  of  the  posterior  Wall  of  the  inguinal  canal  is, 
therefore,  much  more  secure  than  the  outer  part. 

A  hernia  that  protrudes  through  the  posterior  wall  of  the  in- 
guinal canal  external  to  the  deep  epigastric — i.e.,  one  which  passes 
through  the  "internal  ring"  and  works  its  way  downward  along  the 
cord — is  an  oblique,  or  external,  inguinal  hernia,  the  common  va- 
riety. In  those  cases  in  which  the  upper  part,  or  neck,  of  the  infun- 
dibular process  has  failed  to  become  tightly  contracted  around  the 
elements  of  the  cord  right  up  to  the  point  at  which  they  emerge 
from  the  abdomen,  the  predisposition  to  hernia  is,  without  doubt, 
more  pronounced,  and  this  is  especially  the  case  if,  in  addition,  the 
peritoneum,  which  is  normally  adherent  about  the  site  of  the  "in- 
ternal ring,"  shows  a  certain  degree  of  bulging  into  the  mouth  of 
the  patent  infundibular  process. 

A  hernia  that  bulges  forward  through  the  posterior  wall  of  the 
inguinal  canal  to  the  inner  side  of  the  deep  epigastric  artery  is  a 
direct,  or  internal,  inguinal  hernia.  Such  a  hernia  does  not  pass 
through  the  "internal  ring"  and  descend  along  the  course  of  the 
cord,  within  its  sheath  (infundibular  process),  but  bulges  directly 


1.  At  Sixth  Month. 

Testis  located  in  the  back  part  of  the  abdominal  cavity,  covered  by  the  peritoneum  upon 

its  anterior  aspect. 
G,  gubemaculum  of  Hunter. 

IP,  infundibular  process  of  the  transversalis  fascia. 
P,  peritoneum  lining  the  interior  of  abdominal  cavity. 
S,  scrotum. 
T,  testis. 

TF,  transversalis  fascia. 
VD,  vas  deferens. 

2.  At  the  Seventh  Month. 

The  testis  has  descended  into  the  inguinal  region  toward  the  mouth  of  the  infundibular 
process — future  internal  inguinal  ring. 

3.  At  the  Eighth  Month. 

The  testis  has  entered  the  infundibular  process,  carrying  a  process  of  the  peritoneum 

with  it. 
VP,  vaginal  process  of  peritoneum. 

4.  At  Ninth  Month. 

Testis  has  reached  the  bottom  of  the  infundibular  process, — scrotum, — carrying  process 
of  peritoneum  with  it. 

5.  Third  to  Fourth  Week  after  Birth. 

Testis  is  located  in  the  bottom  of  the  infundibular  process — scrotum.  Obliteration 
has  begun  in  the  vaginal  process. 

•J.    Several  Months  after  Birth. 

Normal  adult  condition. 

Testis  rests  in  bottom  of  infundibular  process — scrotum.  The  vaginal  process  which 
accompanied  the  testis  in  its  descent  has  become  obliterated  except  for  that  portion 
of  its  extent  which  corresponds  to  the  testis.  This  remains  as  the  tunica  vaginalis 
testis. 

CT,  cavity  of  tunica  vaginalis  testis. 


Fig.  150. — Descent  of  the  Testis. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  369 

forward  into  the  inguinal  canal,  to  the  inner  side  of  the  cord,  and, 
besides  the  transversalis  fascia,  it  may  have  to  push  the  conjoined 
tendon,  etc.,  before  it,  or  else  force  its  way  between  the  fibers  of 
this  structure.  These  accessory  structures  form  a  strong  barrier 
against  the  formation  of  a  direct  hernia,  which  variety  is  much 
less  common  than  the  oblique. 

In  the  female  the  inguinal  canal  and  rings  are  all  less  well  de- 
veloped than  in  the  male.  The  round  ligament  is  a  thin  structure, 
often  difficult  to  find.  After  passing  through  the  inguinal  canal 
it  emerges  from  the  external  ring,  and  is  then  lost  in  the  connect- 
ive tissue  about  the  external  ring  and  in  the  labia  majora. 

Inguinal  hernia  is  comparatively  infrequent  in  the  female. 
When  it  occurs,  it  is  analogous  to  that  in  the  male,  and  may  de- 
scend into  the  labia  majora. 

The  Descent  of  the  Testes.  —  The  testes  (ovaries  in  the 
female)  are  developed  within  the  abdomen  from  the  Wolffian  body, 
and  in  early  foetal  life  they  are  situated  in  the  back  part  of  the 
abdominal  cavity  near  the  kidneys.  They  lie  not  within  the  peri- 
toneal cavity,  but,  like  the  kidney,  behind  the  peritoneum,  which 
is  adherent  to  their  front  surface.  From  this  position,  the  testes, 
during  the  later  months  of  fcetal  life,  gradually  descend.  They  de- 
scend behind  the  peritoneum  and  enter  the  infundibular  process 
through  its  mouth,  the  "internal  ring."  Finally,  during  the  last 
month  of  intra-uterine  life  they  arrive  at  their  normal  destination, 
the  bottom  of  the  scrotal  pouch. 

The  ovaries  descend  in  an  analogous  manner,  but  do  not  pass 
out  of  the  abdominal  cavity. 

Preparatory  to  the  descent  of  the  testis  there  is  a  pouch-like 
bulging  of  the  lower  part  of  the  anterior  abdominal  wall  in  either 
inguinal  region.  A  shallow  pouch  is  thus  formed  on  either  side, 
which  gradually  becomes  deeper,  and  finally  the  two  join  together 
in  the  middle  line  to  form  the  scrotum.  Each  of  these  pouches  is 
lined  on  its  internal  aspect  by  a  sac-like  prolongation  from  the  trans- 
versalis fascia  (infundibular  process).  These  pouches  are  empty 
and  ready  to  receive  the  testes. 

Eeaching  from  the  testis  as  it  lies  within  the  abdomen,  down- 
ward into  the  bottom  of  the  infundibular  process  (scrotum),  there 
is  a  musculo-fibrous  structure,  the  gubernaculum  of  Hunter.  It 
serves  to  lead  the  testis  down  into  the  scrotal  sac. 

About  the  sixth  month  of  foetal  life  the  descent  of  the  testis 


370  HERNIA,  ETC. 

begins.  The  gubernaculum  contracts  and  draws  the  testis  downward 
toward  the  inguinal  region.  About  the  seventh  month  the  testis 
arrives  at  the  "internal  ring,"  the  wide-open  mouth  of  the  infun- 
dibular process.  The  testis  then  passes  into  the  infundibular  proc- 
ess, and,  as  it  does  so,  it  brings  a  bag-like  process  of  the  peritoneum, 
which  is  adherent  to  it,  with  it.  This  is  called  the  vaginal  process 
of  the  peritoneum.  At  the  eighth  month  the  testis  is  found  in  the 
infundibular  pouch,  together  with  the  vaginal  process  of  the  peri- 
toneum, which  accompanies  it,  and  during  the  last  month  of  intra- 
uterine life  it  is  found  at  the  bottom  of  the  infundibular  pouch,  the 
scrotum,  together  with  its  vaginal  peritoneal  process. 

The  testis  may  be  interrupted  in  its  journey  into  the  scrotum 
at  any  point,  and  may  remain  stationary  either  in  the  abdomen  or 
in  the  inguinal  canal.  This  condition  occasionally  complicates  con- 
genital hernia.  After  the  testis  has  reached  the  bottom  of  the 
scrotal  sac,  the  peritoneal  pouch,  which  accompanied  it,  becomes, 
for  that  part  of  its  extent  which  corresponds  to  the  vas  deferens, 
gradually  obliterated.  This  process  of  obliteration  commences  in 
the  middle  of  the  tube  and  extends  upward  toward  its  abdominal 
orifice,  and  downward  toward  the  testis,  and,  in  the  adult,  this  ob- 
literated portion  of  the  vaginal  process  is  represented  only  by  a 
fibrous  strand  that  is  found,  together  with  the  vas  deferens,  etc., 
inclosed  within  the  proper  sheath  of  the  cord. 

The  lower  part  of  the  vaginal  process,  that  portion  which  corre- 
sponds to  the  testis,  remains  permanently  as  the  tunica  vaginalis 
testis.  At  birth  the  canal  of  the  vaginal  process  is  still  pervious, 
but  very  much  shrunken,  and  becomes  rapidly  obliterated  during 
the  first  few  weeks  of  extra-uterine  life. 

If  the  peritoneal  pouch,  the  vaginal  process,  which  accompanies 
the  testis  in  its  descent,  remains  pervious  after  birth  throughout 
its  whole  extent,  and,  if  its  orifice  is  large  enough  to  permit,  a  coil 
of  intestine  may  enter;   and  we  shall  then  have  a  congenital  hernia. 

In  the  female  the  round  ligament  is  the  remains  of  the  guber- 
naculum.  The  ovary  descends  like  the  testis,  but  does  not  leave  the 
abdominal  cavity;  it  remains  in  the  pelvis.  It  does,  however,  ex- 
ceptionally leave  the  abdominal  cavity,  and  may  then  be  found  in 
the  labia  majora.     Congenital  hernia  is  uncommon  in  the  female. 

To  recapitulate:  There  are  two  varieties  of  inguinal  hernia, 
the  direct,  or  internal,  and  the  oblique,  or  external.  The  direct 
is  always  acquired,  and  is  less  common  than  the  indirect.     In  this 


Fig.  151. — Normal  Condition  of  Inguinal  Region,  Scrotum,  etc.  Testis  in  bottom 
of  scrotum  and  vaginal  process  obliterated.  CT,  cavity  of  tunica  vaginalis  testis,; 
IN,  intestine  within  abdominal  cavity;  IR,  internal  inguinal  ring — the  mouth  of  the 
original  infundibular  process  of  the  transversalis  fascia;  P,  peritoneum  lining  ab- 
dominal cavity ;  TF,  transversal  is  fascia  ;  I'D,  vas  deferens;  VP,  vaginal  process  of 
peritoneum — obliterated. 


Fig.  152. — Condition  of  Parts  in  Presence 
of  a  Congenital  (Oblique  Inguinal)  Hernia. 
Note  that  the  vaginal  process  is  patent,  unoblit- 
erated,  and  that  a  coil  of  intestine  has  entered. 


Fig.  153. — Condition  of  Parts  in  Presence 
of  an  Acquired  Oblique  Inguinal  Hernia.  Note 
that  the  vaginal  process  {VP)  is  obliterated  and 
that  a  coil  of  intestine  has  pushed  its  way 
down  into  the  original  infundibular  process 
(sheath  of  the  spermatic  cord) ,  driving  a  new 
process  of  peritoneum  (S)  before  it.  This 
peritoneal  process  forms  the  sac  of  the  hernia. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  371 

variety  a  pouch  of  peritoneum  (the  hernial  sac) — containing,  for  ex- 
ample, a  loop  of  gut — simply  forces  that  part  of  the  posterior  wall 
of  the  inguinal  canal  that  lies  to  the  inner  side  of  the  deep  epigastric 
artery  before  it  into  the  inguinal  canal,  and  finally  down  through 
the  external  ring. 

The  oblique  variety  may  be  either  congenital  or  acquired. 

A  congenital  hernia  is  due  to  the  absence  of  obliteration  in  the 
vaginal  peritoneal  process.  If  this  process  remains  patent  through- 
out its  entire  length,  the  hernial  contents — for  example,  a  coil  of  gut 
— simply  drop  into-  the  open  pouch,  and  we  have  the  usual  form  of 
congenital  hernia. 

An  acquired  oblique  hernia  is  produced  after  the  vaginal  process 
has  become  completely  and  permanently  obliterated.  In  this  variety 
the  contents — for  example,  a  coil  of  gut — must  force  an  entirely  new 
pouch  of  peritoneum,  which  constitutes  the  hernial  sac,  before  it. 
This  peritoneal  sac  enters  the  mouth  of  the  infundibular  process 
("internal  ring")  like  a  wedge,  and  works  its  way  downward  along  the 
spermatic  cord,  inclosed  within  the  sheath  of  the  cord  (infundibular 
process),  which  it  simply  distends;  or  else,  after  passing  through  the 
internal  ring  into  the  infundibular  process  (sheath  of  the  cord),  it 
causes  a  bulging  of  a  circumscribed  portion  of  the  sheath  of  the  cord, 
with  the  result  that  a  pocket,  or  pouch,  is  formed,  which  is  really 
an  offshoot  from  the  proper  sheath  of  the  cord,  and  in  this  pouch  the 
hernial  peritoneal  sac  is  found,  together  with  the  hernial  contents. 

An  acquired  hernia  may  traverse  the  whole  length  of  the  in- 
guinal canal  and  enter  the  scrotum,  but  its  sac  is  always  entirely 
distinct  from  the  original  vaginal  peritoneal  process,  and  its  con- 
tents are  never  to  be  found  in  the  same  cavity  with  the  testis,  as 
is  the  case  in  the  congenital  variety. 

A  partial  obliteration  of  the  vaginal  process  of  the  peritoneum 
may  occur,  and  we  may  then  have  an  infantile,  or  encysted,  hernia. 
In  this  case  the  vaginal  process  is  occluded  at  or  near  its  mouth, 
but  remains  open  throughout  a  part  of  its  extent  below.  "We  then 
have  a  hernia,  with  its  own  newly  acquired  peritoneal  sac,  like  an 
ordinary  acquired  hernia,  passing  through  the  internal  ring  and 
downward  within  the  sheath  of  the  cord,  pushing  the  closed,  but 
unobliterated,  vaginal  peritoneal  process  in  front  of  it.  When  such  a 
hernia  is  operated  upon,  it  looks  as  though  there  were  two  separate 
and  distinct  sacs.  The. unobliterated  vaginal  process,  within  which 
the  testis  is  found,  is  entered  first,  and  then  a  second  serous  sac,  the 


372  HERNIA,  ETC. 

true  hernial  sac,  is  met  with  and  incised,  and  within  this  the  hernial 
contents  are  encountered. 

The  Femoeal  Kegion. — The  area  immediately  helow  Poupart's 
ligament  is  known  as  the  femoral  region. 

The  Fascia  Lata  is  exposed  after  the  skin  and  superficial  fascia 
have  been  removed.  This  is  a  strong,  aponeurotic  layer  which  en- 
tirely surrounds  the  muscles  of  the  thigh,  and  serves  to  hind  them 
into  a  compact  mass.  It  is  attached  above,  in  front,  to  the  whole 
length  of  Poupart's  ligament,  from  the  pubic  spine  to  the  anterior 
superior  iliac  spine;  externally,  to  the  crest  of  the  ilium;  behind, 
to  the  sacrum;  and,  internally,  to  the  rami  of  the  pubes  and  ischium. 

Just  below  Poupart's  ligament,  where  the  internal  saphenous 
vein  enters  the  femoral  vein,  the  fascia  lata  presents  an  oval  open- 
ing, the  saphenous  opening.  It  is  only  exposed  after  the  cribriform 
fascia  (that  part  of  the  deep  layer  of  the  superficial  fascia  which  is 
attached  to  the  margins  of  the  saphenous  opening)  has  been  re- 
moved. The  outer  margin  of  the  saphenous  opening  is  sharp  and 
curved,  and  was  called  by  Allan  Burns  the  falciform  process.  If 
the  falciform  process  is  traced  upward  and  inward,  it  is  found  to  be 
continuous  with  the  inner  end  of  Poupart's  ligament  and  with  Gim- 
bernat's  ligament,  some  of  its  fibers  being  attached,  with  this  latter 
ligament,  to  the  pubic  bone.  Below,  the  falciform  process  is  seen 
to  curve  inward  underneath  the  internal  saphenous  vein,  becoming 
continuous  here  with  that  part  of  the  fascia  lata  which  covers  the 
pectineus  muscle  (pubic  portion  of  the  fascia  lata).  The  free  edge  of 
the  falciform  process,  and  that  part  of  the  fascia  lata  external  to 
it,  cover  the  femoral  sheath  upon  its  anterior  aspect,  and  are  known 
as  the  "iliac  portion"  of  the  fascia  lata.  It  is  attached  above  to  the 
whole  length  of  Poupart's  ligament,  and  externally  is  continuous 
with  the  sheath  of  the  sartorius  muscle. 

That  portion  of  the  fascia  lata  upon  which  the  internal  saphe- 
nous vein  rests,  and  which  covers  the  pectineus  muscle,  may  be  traced 
upward,  under  Poupart's  ligament,  as  far  as  the  ilio-pectineal  line,  to 
which  it  is  attached,  and  from  which  the  pectineus  muscle  arises. 
This  is  known  as  the  "pubic  portion"  of  the  fascia  lata.  Beneath  the 
femoral  vessels  this  pubic  portion  of  the  fascia  lata  is  continuous, 
externally,  with  the  fascia  which  covers  the  ilio-psoas  muscle  (fascia 
iliaca).  Above,  under  Poupart's  ligament,  this  fascia,  which  covers 
the  pectineus  muscle,  is  thickened,  and  is  known  as  the  pubic  liga- 
ment of  Cooper.    These  two  portions  of  the  fascia  lata,  the  iliac  and 


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SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  373 

pubic  portions,  are  so  arranged  that  a  slit-like  opening,  the  saphenous 
opening,  exists  between  them,  and  through  this  the  internal  saphe- 
nous vein  joins  the  femoral  vein. 

The  femoral  vessels,  inclosed  within  their  sheath,  are  sand- 
wiched in  between  these  two  portions  of  the  fascia  lata,  resting 
behind  upon  the  fascia  which  covers  the  pectineus  and  ilio-psoas 
muscles,  and  covered  in  front  by  the  iliac  portion  of  the  fascia  lata. 
The  two  portions  of  the  fascia  lata,  which  have  just  been  described, 
the  iliac  and  pubic  portions,  are  simply  parts  of  one  and  the  same 
fascia,  and  are  seen  to  be  directly  continuous  with  each  other,  below 
the  saphenous  opening  upon  the  front  of  the  thigh.  The  pubic 
portion  of  the  fascia  lata,  which  corresponds  to  the  pectineus  muscle, 
is,  as  already  said,  continuous  externally,  behind  the  sheath  of  the 
femoral  vessels,  with  the  iliac  fascia,  which  invests  the  ilio-psoas 
muscle.  One  should  not  confuse  the  names  "iliac  portion  of  the 
fascia  lata"  with  "iliac  fascia/' 

The  Space  Beneath  Poupart's  Ligament.  —  Through  this  space 
the  ilio-psoas  muscle  and  the  anterior  crural  nerve  and  the  femoral 
vessels  pass  out  of  the  abdomen  into  the  thigh. 

The  ilio-psoas  muscle,  with  the  anterior  crural  nerve,  occupies 
the  outer  part  of  the  space.  The  ilio-psoas  muscle  is  a  thick  mass 
of  muscle  which  has  its  origin  within  the  abdomen  from  the  iliac 
fossa,  bodies  of  the  lumbar  vertebras,  etc.  It  consists  of  the  psoas 
and  iliacus  muscles,  and  passes  downward  under  Poupart's  ligament 
into  the  thigh,  where  it  is  attached  to  the  lesser  trochanter  of  the 
femur  and  to  the  surface  of  the  bone  immediately  below  this. 

Within  the  abdomen  the  ilio-psoas  muscle  is  covered  by  a  thick 
fascia,  the  fascia  iliaca,  which  is  attached  to  the  bodies  of  the  lumbar 
vertebrae  and  to  the  sacrum,  to  the  crest  of  the  ilium,  and  to  the 
brim  of  the  pelvis. 

At  Poupart's  ligament,  that  part  of  the  iliac  fascia  which  covers 
the  outer  portion  of  the  ilio-psoas  muscle — i.e.,  corresponding  to  the 
outer  third  of  Poupart's  ligament — does  not  pass  down  into  the 
thigh  with  the  muscle,  but  is  attached  to  Poupart's  ligament,  whence 
it  is  reflected  upward,  becoming  continuous  with  the  transversalis 
fascia,  which  lines  the  whole  posterior  surface  of  the  anterior  ab- 
dominal wall.  Internal  to  this,  however,  corresponding  to  the  inner 
portion  of  the  ilio-psoas  muscle,  the  fascia  which  covers  the  muscle 
passes  with  the  muscle,  underneath  Poupart's  ligament,  down  into  the 
thigh,  and  in  the  upper  part  of  the  thigh  is  continuous,  behind  the 


374  HERNIA,  ETC. 

sheath  of  the  femoral  vessels,  with  the  fascia  which  covers  the  pectin- 
ens  muscle  (pubic  portion  of  the  fascia  lata).  Immediately  beneath 
Poupart's  ligament  the  iliac  fascia  is  thickened,  and  this  thickened 
portion  is  called  the  ilio-pectineal  ligament.  This  is  not  an  isolated 
ligamentous  band  of  fibers,  but  simply  a  thickened  portion  of  the 
fascia  iliaca  as  it  passes  with  the  ilio-psoas  muscle  under  Poupart's 
ligament  into  the  thigh.  It  extends  from  the  junction  of  the  outer 
and  middle  thirds  of  Poupart's  ligament  downward  and  inward  to 
the  ilio-pectineal  eminence,  and  serves  thus  to  divide  the  space  un- 
derneath Poupart's  ligament  into  two  portions:  an  outer,  the  ilio- 
psoas space,  which  contains  the  ilio-psoas  muscle  and  the  anterior 
crural  nerve,  and  an  inner  and  upper,  the  femoral  space,  through 
which  the  femoral  vessels  pass  from  the  abdomen  into  the  thigh. 

The  femoral  space  is  bounded  above  by  Poupart's  ligament; 
below,  it  is  bounded  externally  by  the  ilio-pectineal  ligament,  and, 
internally,  by  the  pubic  ligament  of  Cooper.  The  so-called  pubic 
ligament  of  Cooper  is  simply  the  thickened  upper  portion  of  the 
fascia  which  covers  the  pectineus  muscle.  Internally,  the  space  is 
bounded  by  the  sharp,  curved  edge  of  Gimbernat's  ligament.  The 
space  is  limited  externally  by  the  junction  of  Poupart's  ligament 
and  the  ilio-pectineal  ligament. 

The  Femoral  Sheath. — As  the  femoral  vessels  pass  into  the  thigh, 
through  the  femoral  space,  they  are  inclosed  in  a  special  connective 
tissue  sheath,  and  rest  upon  the  ilio-psoas  and  pectineus  muscles. 
The  femoral  sheath  is  a  funnel-shaped  connective  tissue  envelope 
which  is  prolonged  downward  from  the  margins  of  the  femoral  space, 
inclosing  the  vessels  as  they  pass  into  the  thigh.  Corresponding  to 
its  commencement  at  Poupart's  ligament,  the  femoral  sheath  is  wide- 
mouthed,  and  attached  all  around  to  the  margins  of  the  femoral 
space.  Above,  it  is  attached  to  Poupart's  ligament;  below,  to  the 
ilio-pectineal  ligament  (thickened  portion  of  the  fascia  covering  the 
ilio-psoas  muscle)  and  to  the  ligament  of  Cooper  (thickened  upper 
portion  of  the  fascia  that  covers  the  pectineus  muscle).  Internally, 
it  is  attached  to  the  edge  of  'Gimbernat's  ligament.  The  femoral 
sheath  is  continued  but  a  short  distance  downward  upon  the  femoral 
vessels,  becoming  narrow  and  contracted  below,  and  closely  applied 
to  the  walls  of  the  vessels. 

The  femoral  sheath  is  divided  into  three  compartments,  which 
are  entirely  separate  and  distinct  from  each  other,  by  connective 
tissue    septa.      In   the    outer    compartment    the   femoral    artery   is 


Fig.  156.— The  Pelvis  and  Ligaments  of  the  Ilio-pubic  Region.  FS,  femoral 
space;  G,  Gimbernat's  ligament;  IP,  ilio-pectineal  ligament;  IPS,  ilio-psoas  space; 
P,  Poupart's  ligament ;  PS,  pubic  spine. 


Fig.  157.— Femoral  Space.  Femoral  vessels  and  sheath  as  they  pass  under  Pou- 
part's ligament  have  been  cleared  away.  Poupart's  ligament  lifted  upon  hook.  The 
iliacus  and  psoas  muscles  are  covered  by  their  fascia,  the  fascia  iliaca ;  IP,  ilio-pectineal 
ligament— thickened  portion  of  the  fascia  that  invests  the  ilio-psoas  muscle ;  LP, 
Poupart's  ligament;  P,  pubic  ligament  of  Cooper— upper  thickened  part  of  the  fascia 
that  covers  the  pectineus  muscle. 


Fig.  158. — Deep  Femoral  Region — the  Femoral  Vessels,  etc.,  Cut  Across  as  they  Emerge  Under 
Poupart's  Ligament.  AC,  anterior  crural  nerve  ;  CT,  edge  of  the  conjoined  tendon;  CR,  crural  ring; 
E,  dotted  line  indicates  the  course  of  the  deep  epigastric  artery  ;  FS,  femoral  sheath;  G,  Gimbernat's 
ligament;  IP,  ilio-pectineal  ligament;  P,  Poupart's  ligament;  PE,  pectineus  muscle.  This  muscle 
rests  upon  the  pubic  bone  and  is  covered  by  its  fascia, — the  pectineal  fascia, — which  is  somewhat 
thickened  immediately  beneath  Poupart's  ligament,  where  it  is  known  as  the  pubic  ligament  of  Cooper. 
It  will  be  noticed  that  the  femoral  sheath  is  divided  into  three  compartments  :  the  outer  for  the  femoral 
artery  ;  the  middle  for  the  femoral  vein  ;  the  inner  (CR)  is  the  crural  ring,  the  mouth  of  the  crural 
canal. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  375 

lodged;  in  the  middle,  the  femoral  vein;  the  inner  compartment 
contains  a  lymphatic  gland  and  some  loose  connective  tissue,  and 
gives  passage  to  the  lymphatic  vessels  that  enter  the  ahdomen  from 
the  lower  extremity.  This  space,  the  inner,  is  called  the  crural  canal. 
It  is  inclosed  within  the  femoral  sheath,  and  reaches  from  Gim- 
bernat's  ligament  downward  upon  the  inner  side  of  the  femoral  vein 
as  far  as  the  junction  of  the  internal  saphenous  vein  with  the  fem- 
oral, at  which  point  the  crural  canal  ceases  to  exist,  because  here  the 
femoral  sheath  is  applied  directly  to  the  wall  of  the  femoral  vein. 

The  orifice  of  this  crural  space,  or  canal,  is  called  the  crural 
ring.  The  crural  ring  is  bounded  above  by  Poupart's  ligament;  be- 
low, by  the  pectineus  muscle  and  the  fascia  which  covers  it,  and 
which  is  here  thickened  and  called  the  pubic  ligament  of  Cooper; 
internally,  by  Gimbernat's  ligament;  and,  externally,  by  the  femoral 
vein.  A  femoral  hernia,  as  it  descends  into  the  thigh,  usually  oc- 
cupies this  crural  canal,  lying  to  the  inner  side  of  the  femoral  vein, 
and,  just  above  the  junction  of  the  internal  saphenous  vein  with 
the  femoral  vein,  where  the  crural  canal  terminates,  it  presents  in 
the  saphenous  opening. 

Study  of  the  Inguinal  and  Femoral  Regions  from  Within  the 
Abdomen. — To  examine  these  regions  from  within  the  abdomen,  an 
incision  is  made  through  the  anterior  abdominal  wall,  on  either  side, 
passing  from  the  umbilicus  outward  and  then  downward  to  a  point 
just  external  to  the  anterior  superior  spine  of  the  ilium. 

The  Inguinal  Kegion. — The  bladder  is  seen  to  occupy  the  an- 
terior median  portion  of  the  true  pelvis,  and  when  moderately  full 
reaches  as  high  as  the  symphysis.  It  will  be  observed  that  the 
peritoneum  which  covers  the  bladder  is  continued  forward  from  the 
fundus  of  that  organ  over  on  to  the  posterior  surface  of  the  ante- 
rior wall  of  the  abdomen,  where  it  presents  several  folds,  or  ridges, 
which  are  caused  by  the  projection  of  prominent  underlying  struct- 
ures. These  several  ridges,  or  plicas,  converge  in  a  direction  upward, 
toward  the  umbilicus,  and  include  between  them  areas  which  are 
more  or  less  depressed,  and  which  are  called  fovea;.  In  the  middle  line, 
reaching  from  the  summit  of  the  bladder  upward  to  the  umbilicus,  the 
peritoneum  is  raised  in  the  shape  of  a  fold  by  the  superior  ligament  of 
the  bladder,  the  remains  of  the  fcetal  urachus.  External  to  this,  pass- 
ing from  either  side  of  the  body  of  the  bladder  upward  to  the  um- 
bilicus, there  is  a  fold,  beneath  which  the  obliterated  hypogastric 
artery  runs.    Still  more  externally  there  is  another  fold,  which  corre- 


376 


HERX1A,  ETC. 


Fig.  159. — The  Inguinal  and  Femoral  Regions  from  TVithin  the  Abdomen.  Upon 
the  right  side  the  peritoneum  has  been  stripped  off,  exposing  the  transversalis  fascia. 
AC,  anterior  crural  nerve  imbedded  in  the  ilio-psoas  muscle;  D,  semilunar  fold  of 
Douglas — the  lower  edge  of  the  posterior  layer  of  the  sheath  of  rectus;  E,  deep  epi- 
gastric artery;  E1,  plica  epigastriea  (the  deep  epigastric  vessels  are  situated  beneath 
this  fold);  F.I.,  cut  edge  of  the  fascia  iliaca,  which  invests  the  ilio-psoas  muscle;  GL, 
Gimbernat's  ligament;  H,  obliterated  hypogastric  artery;  I.E.,  fovea  inguinalis  externa; 
/./.,  fovea  inguinalis  interna;  IL,  sawn  surface  of  the  ilium;  IPL,  ilio-pectineal  liga- 
ment, a  thickened  portion  of  the  iliac  fascia;  P,  cut  edge  of  the  peritoneum;  P. I., 
cut  edge  of  the  ilio-psoas  muscle;  PL,  Poupart's  ligament;  PM,  pectineus  muscle  cov- 
ered by  its  fascia,  which  is  here  somewhat  thickened  and  is  known  as  the  pubic  liga- 
ment of  Cooper;  SY,  fovea  supravesical ;  7.L.,  plica  vesico-umbilicalis  lateralis  (the 
obliterated  hypogastric  artery  lies  beneath  this  fold);  T.M.,  plica  vesico-umbilicalis 
media  (the  urachus,  which  reaches  from  the  fundus  of  the  bladder  to  the  umbilicus,  is 
situated  beneath  the  fold).  Above  the  middle  of  Poupart's  ligament  there  is  an  opening 
in  the  transversalis  fascia — internal  inguinal  ring — mouth  of  the  infundibular  process. 
The  vas  deferens  and  other  component  parts  of  the  spermatic  cord  which  pass  in  and 
out  of  the  abdomen  through  this  orifice  have  been  cut  short  in  the  picture;  this  open- 
ing is  the  exit  for  indirect  inguinal  hernia.  Beneath  Poupart's  ligament  the  femoral 
vessels,  inclosed  with  their  sheath,  are  seen.  These  structures  have  been  divided  close 
to  Poupart's  ligament.  The  femoral  sheath  occupies  the  space  described  as  the  femoral 
space,  and  is  divided  into  three  compartments — the  outer  for  the  artery  and  the  middle 
for  the  vein;    the  orifice  of  the  inner  compartment  is  called  the  crural  ring. 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  377 

sponds  to  the  course  of  trie  deep  epigastric  artery;  this  is  a  large  vessel 
given  off  from  the  external  iliac  (femoral)  just  before  it  passes  out  of 
the  abdomen  under  Poupart's  ligament,  and  is  accompanied  by  one  or 
two  veins.  The  peritoneal  folds  are  named,  respectively,  the  plica 
vesico-umbilicalis  media,  corresponding  to  the  urachus,  in  the  middle 
line;  the  plica  vesico-umbilicus  lateralis,  corresponding  to  the  oblit- 
erated hypogastric  artery;  and  the  plica  epigastrica,  corresponding  to 
the  epigastric  artery  and  vein.  Between  these  peritoneal  folds,  or 
plica,  are  the  fovea?,  already  mentioned,  which  are  deeper  in  some 
subjects  than  in  others.  External  to  the  plica  epigastrica  is  the  fovea 
inguinalis  externa.  Between  the  plica  epigastrica  and  the  plica  vesico- 
umbilicalis  lateralis  is  the  fovea  inguinalis  interna.  Between  the  plica 
vesico-umbilicalis  lateralis  and  the  plica  vesico-umbilicalis  media  is 
the  fovea  supravesicalis. 

The  Fovea  Inguinalis  Externa. — After  the  peritoneum  has  been 
stripped  off  from  this  area,  and  some  loose  connective  tissue  (sub- 
peritoneal connective  tissue)  which  lies  beneath  it  has  been  removed, 
we  expose  the  transversalis  fascia.  This  fascia  presents  the  opening 
into  the  infundibular  process,  the  so-called  "internal  ring,"  which  is 
located  about  half  an  inch  above  the  middle  of  Poupart's  ligament. 
The  vas  deferens,  spermatic  artery,  veins,  etc.,  structures  of  which 
the  spermatic  cord  is  formed  (in  the  female,  the  round  ligament), 
pass  into  this  opening.  The  lower,  inner,  margin  of  the  internal 
ring  presents  a  distinct,  sharp,  crescentic  edge.  A  probe  or  the  finger 
can  be  introduced  into  the  internal  ring,  and  may  be  insinuated  for 
a  greater  or  less  distance  into  the  sheath  of  the  spermatic  cord, 
infundibular  process.  About  the  internal  ring  the  peritoneum  is 
more  or  less  plaited  upon  itself,  and  is  adherent  to  the  margins  of 
the  ring,  and  may  bulge  for  a  certain  distance  into  it.  A  fibrous 
cord  passes  from  the  peritoneum  into  the  internal  ring,  and  may  be 
traced  downward  into  the  infundibular  process  along  with  the  other 
constituents  of  the  spermatic  cord.  This  fibrous  band,  or  string, 
represents  the  shrunken,  obliterated  vaginal  process  of  peritoneum 
which  accompanies  the  testis  in  its  descent  into  the  scrotum.  Di- 
rected upward  and  inward  toward  the  umbilicus,  and  passing  to  the 
inner  side  of  the  internal  ring  is  the  deep  epigastric  artery,  with  its 
accompanying  vein.  If  a  hernial  protrusion  occurs  in  this  location, 
the  process  of  peritoneum  which  forms  the  sac  of  the  hernia  forces 
its  way  through  the  internal  ring  (to  the  outer  side  of  the  deep 
epigastric),  and  gradually  works  its  way  downward  within  the  fibrous 


378  HERNIA,  ETC. 

sheath  of  the  cord,  which  is  the  remains  of  the  original  infun- 
dibular process,  and  we  then  have  a  typical  external,  or  oblique, 
inguinal  hernia.  The  coverings  of  this  variety  of  hernia,  from 
within  outward,  are,  besides  its  peritoneal  sac,  the  infundibular  fascia 
(pouch  derived  from  fascia  transversalis),  cremaster  muscle  and  fascia, 
deep  la}rer  of  the  superficial  fascia  (spermatic  fascia),  superficial  layer 
of  the  superficial  fascia  (fat),  and  the  skin. 

If  a  congenital  hernia  is  present,  the  vaginal  peritoneal  process 
which  accompanied  the  testis  in  its  descent  into  the  scrotum  is  found 
patent,  unobliterated,  reaching  downward  through  the  internal  ring 
and  along  the  cord  within  its  sheath  (infundibular  process)  to  the 
bottom  of  the  scrotum. 

The  coverings  of  a  congenital  hernia  are  the  same  as  those  given 
for  the  oblique,  or  external,  acquired  variety.  The  difference  be- 
tween the  oblique  acquired  and  the  congenital  is  that  the  acquired 
must  form  a  peritoneal  sac  for  itself,  whereas  the  congenital  finds 
its  sac  already  present;  i.e.,  the  unobliterated  vaginal  peritoneal 
process. 

The  Fovea  Inguinalis  Interna. — This  is  the  space  between  the 
plica  epigastrica  and  the  plica  vesico-umbilicalis  lateralis.  After  the 
peritoneum  has  been  stripped  away  from  this  part  we  expose  the  trans- 
versalis fascia.  The  fovea  inguinalis  interna  is  the  part  which  is  in- 
volved in  direct  inguinal  hernia.  It  presents  no  opening.  In  the 
event  of  a  direct  inguinal  hernia,  a  bulging  or  pouching  of  this  part 
of  the  posterior  wall  of  the  inguinal  canal  occurs,  and  the  hernial 
sac,  composed  of  the  parietal  peritoneum,  will  have  as  coverings, 
from  within  outward,  the  various  layers  that  form  this  part  of  the 
posterior  wall  of  the  inguinal  canal,  viz.:  the  fascia  transversalis, 
the  conjoined  tendon,  and  the  triangular  ligament,  and,  in  addition, 
the  deep  layer  of  the  superficial  fascia  (spermatic  fascia),  the  super- 
ficial layer  of  the  superficial  fascia  (fat),  and  the  skin. 

The  neck  of  the  sac  in  a  direct  inguinal  hernia  lies  to  the  inner 
side  of  the  deep  epigastric  vessels. 

Fovea  Supravesical.  —  This  is  the  space  between  the  plica 
vesico-umbilicalis  lateralis  and  media.  Its  floor  is  formed  by  the 
rectus  muscle.  This  region  is  of  but  little  surgical  interest,  and  is 
not  the  site  of  hernial  protrusions. 

The  Femoral  Kegion. — Below  Poupart's  ligament  we  have  the 
femoral  region.  This  part  is,  at  times,  depressed,  and  is  called  the 
fossa  cruralis.     If  we  dissect  away  the  peritoneum,  we  expose  Pou- 


SURGICAL  ANATOMY  OF  THE  GROIN,  ETC.  379 

part's  ligament,  passing  from  the  anterior  superior  spinous  process 
of  the  ilium  inward  and  downward,  to  be  attached  to  the  spine  of 
the  pubes.  From  the  lower  border  of  Poupart's  ligament,  just  be- 
fore its  attachment  to  the  pubic  spine,  a  triangular  band  of  fibers, 
which  is  attached  to  the  ilio-pectineal  line,  is  given  off.  This  is 
called  Gimbernat's  ligament.  Its  sharp  outer  edge  may  be  readily 
felt. 

Between  Poupart's  ligament  and  the  pubic  bones  there  is  a  large 
space  through  which  the  ilio-psoas  muscle  and  anterior  crural  nerve 
and  the  femoral  vessels  pass  into  the  thigh.  The  ilio-psoas  muscle 
arises  within  the  abdomen  and  passes  down  toward  Poupart's  liga- 
ment in  one  mass,  which  is  invested  by  a  strong  fascia,  the  iliac. 
At  Poupart's  ligament,  the  fascia  that  covers  the  outer  part  of  the 
psoas-iliacus — i.e.,  that  part  of  it  which  corresponds  to  the  outer 
third  of  Poupart's  ligament — is  attached  to  Poupart's  ligament,  and 
is  thence  reflected  upward,  becoming  continuous  with  the  transver- 
salis  fascia,  which  lines  the  whole  posterior  surface  of  the  anterior 
abdominal  wall.  Internal  to  this,  however,  where  the  femoral  ves- 
sels pass  out  under  Poupart's  ligament,  the  fascia  is  continued  down- 
ward with  the  muscle  underneath  Poupart's  ligament,  into  the 
thigh.  As  the  femoral  vessels  descend  into  the  thigh  they  rest  upon 
the  pectineus  and  ilio-psoas  muscles,  separated  from  them,  however, 
by  the  fascia  which  covers  them,  the  pectineal  fascia1  covering  the 
pectineus  muscle,  and  the  iliac  fascia  covering  the  ilio-psoas  muscle. 

The  fascia  iliaca,  immediately  beneath  Poupart's  ligament,  is 
thickened,  and  is  called  the  ilio-pectineal  ligament.  It  reaches  from 
the  junction  of  the  outer  and  middle  thirds  of  Poupart's  ligament  to 
the  ilio-pectineal  eminence,  and  serves  to  divide  the  space  under 
Poupart's  ligament  into  two  portions:  that  for  the  ilio-psoas  muscle 
and  anterior  crural  nerve,  below  and  externally,  and  that  through 
which  the  femoral  vessels  pass,  above  and  internally.  This  latter 
is  called  the  femoral  space.  The  boundaries  of  the  femoral  space 
are,  above,  Poupart's  ligament;  below  and  externally,  the  ilio-pec- 
tineal ligament  (thickened  portion  of  the  iliac  fascia);  below  and 
internally,  the  pubic  ligament  of  Cooper  (the  upper  thickened  por- 
tion of  the  fascia  that  covers  the  pectineus  muscle);  internally,  the 
edge  of  Gimbernat's  ligament. 

As  the  femoral  vessels  pass  down  through  the  femoral  space 


1  That  part  of  the  pubic  portion  of  the  fascia  lata  that  covers  the  pectineus  muscle. 


380  HERNIA,  ETC. 

into  the  thigh,  they  are  inclosed  in  a  connective  tissue  sheath,  which 
is  prolonged  downward  from  the  margins  of  this  space.  It  is  called 
the  femoral  sheath.  The  femoral  sheath  is  divided  into  three  com- 
partments by  septa:  the  outer  contains  the  artery;  the  middle  one, 
the  vein;  the  innermost,  that  between  the  vein  and  the  edge  of 
Gimbernat's  ligament,  is  the  so-called  crural  canal,  and  gives  pas- 
sage to  lymphatics  from  the  thigh  to  the  abdomen.  The  abdominal 
orifice  of  the  crural  canal  is  called  the  crural  ring. 

In  the  event  of  a  femoral  hernia,  a  process  of  peritoneum  (her- 
nial sac)  is  forced  into  the  crural  ring  and  down  through  the  crural 
canal,  appearing  below  in  the  upper  part  of  the  thigh  in  the  saphe- 
nous opening. 

The  coverings  of  a  femoral  hernia,  from  within  outward,  are, 
besides  its  peritoneal  sac,  the  femoral  sheath,  the  deep  layer  of  the 
superficial  fascia  (the  cribriform  fascia),  the  superficial  layer  of  the 
superficial  fascia  (fat),  and  the  skin. 

The  Obturator  Foramen. — This  foramen  is  located  below  the 
brim  of  the  pelvis.  It  is  an  opening  in  the  upper  part  of  the  ob- 
turator membrane,  between  its  upper  edge  and  the  lower  border  of 
the  ramus  of  the  pubes.  This  foramen  gives  exit  to  the  obturator 
artery,  vein,  and  nerve,  and  is  sometimes  the  site  of  a  hernial  protru- 
sion. The  obturator  artery  usually  arises  from  the  external  iliac, 
passes  forward  just  below  the  brim  of  the  pelvis,  and  out  through 
the  obturator  foramen  into  the  thigh.  Occasionally,  however,  this 
artery  is  derived  from  the  deep  epigastric,  close  to  the  origin  of  this 
vessel  from  the  external  iliac  (femoral),  and  in  its  course  to  reach 
the  obturator  foramen  it  is  found  in  close  proximity  to  the  margin 
of  the  crural  ring.  After  its  origin  from  the  deep  epigastric,  in  its 
course  to  reach  the  obturator  foramen,  it  either  passes  around  the 
upper  and  inner  margins  of  the  crural  ring  or  else  it  descends  close 
to  the  inner  wall  of  the  femoral  vein  and  behind  the  outer  border  of 
the  crural  ring. 

OPERATIONS  FOR  HERNIA. 

Herniotomy.  —  Incision  of  the  coverings  of  a  hernia,  opening 
into  the  sac,  and  the  division  of  constricting  rings  or  bands  constitute 
the  operation  of  herniotomy.  The  operation  is  done  for  the  purpose 
of  liberating  a  strangulated  hernia.  The  constriction  may  be  caused 
by  bands  in  the  body  of  the  sac  or  by  the  neck  of  the  sac  itself,  but  in 


OPERATIONS  FOR  HERNIA. 


381 


most  cases  it  is  probably  caused  by  the  firm,  unyielding  ring  by  which 
the  neck  of  the  sac  is  encircled. 

At  one  of  the  usual  sites  of  a  hernial  protrusion  there  is  found  a 
tense,  elastic  tumor.  The  incision  is  placed  over  the  most  prominent 
part  of  the  tumor,  cutting  carefully  through  the  skin  and  the  deeper 
layers  until  the  sac  proper  is  reached.  The  sac  may  then  be  pinched 
up  with  two  forceps  and  incised  between  them,  when  there  is  an 
escape  of  serous  fluid,  and  the  contents  of  the  sac  are  exposed. 


Fig.  160. — Irregular  Origin  of  Obturator  Artery.  In  its  course  into  the 
pelvis  it  lies  close  to  the  inner  side  of  the  femoral  vein.  A,  femoral  artery; 
E,  deep  epigastric  artery;  GL,  Gimbernat's  ligament;  IR,  internal  inguinal 
ring;  O,  obturator  artery;  PL,  Poupart's  ligament;  V,  femoral  vein.  The 
space  between  the  femoral  vein  and  Gimbernat's  ligament  is  known  as  the 
crural  ring,  and  through  this  femoral  hernia  leaves  the  abdomen. 


The  contents  vary;  they  may  consist  of  intestine,  large  or  small; 
of  omentum,  or  of  both;  and  occasionally  there  may  be  other  organs, 
such  as  the  bladder,  ovary,  etc.  After  the  sac  has  been  freely 
opened,  its  contents  should  be  examined.  Any  constricting  bands  in 
the  body  of  the  sac  should  be  divided,  and  an  attempt  then  made  to 
pull  the  gut  down  so  as  to  ease  it  at  the  point  of  constriction;  but 
in  this  effort  much  force  should  not  be  used.     An  effort  is  made  to 


382 


HERNIA,  ETC. 


insert  the  finger  into  the  neck  of  the  sac,  and,  if  this  is  successful,  a 
probe-pointed,  curved  knife  may  be  introduced  upon  the  finger  and 
the  constricting  ring  incised.  If  one  is  unable  to  insert  the  finger 
into  the  neck  of  the  sac,  a  director  may  be  carried  through,  and  upon 
this  the  ring  may  be  divided.  In  freeing  the  constriction,  a  suc- 
cession of  nicks  should  be  made  rather  than  a  single  free  cut,  and 
these  may  be  repeated  until  the  parts  are  liberated. 

For  the  relief  of  an  indirect  inguinal  hernia  the  incision  in  the 


Fig.  161.— Irregular  Origin  of  Obturator  Artery.  In  Its  course  into  the 
pelvis  it  curves  around  the  upper  and  inner  edge  of  the  crural  ring.  Letters 
same  as  160. 


constricting  ring  should  be  directed  upward.  For  a  direct  inguinal 
hernia  the  incision  should  be  directed  upward  and  inward,  toward 
the  umbilicus.  For  a  femoral  hernia  the  incision  should  be  directed 
inward  toward  Gimbernat's  ligament  and  somewhat  upward. 

For  practical  purposes,  if  in  doubt  as  to  the  exact  variety  of  the 
hernia,  the  direction  of  the  liberating  incision  for  both  varieties  of 
inguinal  and  for  femoral  hernia  may  be  upward  and  inward,  toward 
the  umbilicus.     By  cutting  in  this  direction,  upward  and  inward, 


OPERATIONS  FOR  HERNIA.  383 

toward  the  umbilicus,  we  work  in  a  line  which  is  parallel  with  the 
course  of' the  deep  epigastric  vessels,  and  the  danger  of  wounding 
these  is  thus  obviated. 

Occasionally  the  obturator  artery,  as  described  above,  is  given 
off  from  the  deep  epigastric,  and  in  its  course  to  reach  the  obturator 
foramen  this  vessel  would  then  have  a  close  relationship  to  the  neck 
of  the  sac  of  a  femoral  hernia.  From  its  origin,  at  the  deep  epigas- 
tric, the  obturator  artery  either  descends  close  to  the  inner  wall  of 
the  femoral  vein,  and  therefore  behind  the  outer  margin  of  the  crural 
ring,  and  would  thus  lie  to  the  outer  side  of  the  neck  of  a  femoral  her- 
nial sac,  or  else  it  curves  inward  and  then  downward,  behind  the  up- 
per and  inner  borders  of  the  crural  ring,  and  would  then  lie  above  and 
to  the  inner  side  of  a  femoral  hernial  sac.  In  the  first  case,  this  ves- 
sel would  be  out  of  the  way  in  making  the  liberating  incisions  at 
the  crural  ring,  whereas  in  the  second  instance  the  vessel  would  be 
jeoparded  in  making  the  liberating  incisions  if  caution  were  not  exer- 
cised. 

If  the  constriction  at  the  neck  of  the  sac  is  relieved  by  a 
succession  of  nicks,  rather  than  by  a  single  free  incision,  we  will 
be  very  much  less  liable  to  divide  an  abnormally  placed  obturator 
artery.  After  the  contents  of  the  sac  have  been  liberated  they  may 
be  drawn  down  for  examination,  especially  at  the  points  of  constric- 
tion. If  omentum  is  present,  this  may  be  ligated  and  amputated. 
As  to  the  treatment  of  the  gut,  careful  deliberation  must  be  used. 
If  the  gut  is  healthy,  it  may  be  returned  at  once  into  the  abdomen. 
If  doubtful,  one  may  wait  for  a  short  time  to  note  if  it  tends  to  clear 
up.  After  the  gut  has  been  reduced  the  finger  should  be  introduced 
through  the  neck  of  the  sac  in  order  to  make  certain  that  there  are 
no  adhesions  about  the  neck  which  might  continue  to  constrict  the 
gut. 

If  the  gut  is  gangrenous,  or  too  doubtful  to  return  into  the  ab- 
domen, the  incision  in  the  abdomen  at  the  neck  of  the  sac  should 
be  enlarged  and  the  gut  drawn  down  and  resected;  or  else  the  gut 
may  be  allowed  to  remain  without  disturbing  the  adhesions  about  the 
neck  of  the  sac,  and  an  artificial  anus  made  by  incising  the  strangu- 
lated coil  of  gut,  if  it  has  not  already  sloughed  through.  The  wound, 
under  these  circumstances,  should  be  left  open  and  packed. 

Radical  Operation  for  Inguinal  Hernia  (Bassini  Method).  For 
an  Oblique  Acquired  Hernia. — An  incision  is  made  through  the 
skin,  commencing  at  a  point  half  an  inch  above  and  somewhat  ex- 


384 


HERNIA,  ETC. 


fcernal  to  the  middle  of  Poupart's  ligament,  carrying  it  downward 
and  inward  as  far  as  the  spine  of  the  pubes;  or  it  may  be  prolonged 
for  a  short  distance  downward  upon  the  scrotum,  if  necessary.  This 
incision  penetrates  into  the  subcutaneous  fatty  layer.  In  its  upper 
part  the  incision  should  be  deepened  until  the  fibers  of  the  aponeu- 
rosis of  the  external  oblique  are  plainly  visible.  The  fingers  are 
then  introduced  into  this  upper,  deeper  part  of  the  incision,  and  it 


V 


Fig.  162.— Operation  for  Inguinal  Hernia.  Incision  penetrates  through  the 
skin  and  fat,  exposing  the  aponeurosis  of  the  external  oblique.  80,  spermatic 
cord  emerging  from  the  external  inguinal  ring. 


is  torn  open  down  to  its  lower  end.  After  this  has  been  done  the 
aponeurosis  of  the  external  oblique  and  the  pillars  of  the  external 
ring,  through  which  the  cord  emerges,  are  exposed. 

Any  bleeding  points  are  caught  in  artery  forceps;  but  it  is  not 
necessary  to  ligate  them  immediately,  as  the  hemorrhage  usually 
ceases  after  a  few  minutes'  compression. 

A  blunt  director  is  now  passed  into  the  external  ring,  and  car- 


OPERATIONS  FOR  HERNIA.  385 

ried  upward  and  outward  beneath  the  aponeurosis  of  the  external 
oblique  to  a  point  beyond  the  middle  of  Poupart's  ligament,  the 
location  of  the  "internal  ring/'  and  upon  this  the  aponeurosis  is 
divided.  Some  obstruction  to  the  introduction  of  the  director 
through  the  external  ring  will  be  experienced  if  the  deep  layer  of  the 
superficial  fascia,  which  is  attached  to  the  margins  of  the  ring,  has 
not  been  incised. 

The  edges  of  the  split  aponeurosis  of  the  external  oblique  are 
seized  with  artery  forceps  and  separated  with  the  finger  from  the 
structures  which  lie  immediately  beneath.  The  inguinal  canal  is 
thus  laid  open,  and  the  spermatic  cord,  together  with  the  hernial 
sac,  is  exposed.  The  lower,  free  fleshy  edge  of  the  internal  oblique 
muscle  is  seen  arching  inward  over  the  cord  and  hernial  sac.  It  is 
blended  with  the  tendon  of  the  transversalis  muscle  to  form  the  con- 
joined tendon,  which  descends  behind  the  cord,  and  which  can  be  felt 
as  a  strong,  resistant  band  attached  to  the  crest  of  the  pubic  bone. 

The  spermatic  cord,  together  with  the  hernial  sac,  which  is 
usually  found  empty,  unless  its  contents  are  irreducible  or  the  pa- 
tient is  straining,  is  now  hooked  up,  upon  the  finger,  and  we  proceed 
to  separate  the  sac  from  the  cord.  At  times  it  is  difficult  to  recog- 
nize the  sac.  It  is  formed  of  the  pouch  of  peritoneum,  with  some 
loose  connective  tissue  (subperitoneal  connective  tissue  layer)  and 
is  situated  within  the  proper  sheath  of  the  spermatic  cord  (infundib- 
ular process  of  transversalis  fascia),  which  must  be  incised  or  torn  in 
order  to  expose  it  (the  sac).  The  sac  has  a  peculiar,  white,  aponeurotic 
appearance,  and  may  be  very  thin  or  of  moderate  thickness.  The  isola- 
tion of  the  sac  from  the  cord  is  accomplished  chiefly  by  tearing  and 
separating  with  the  fingers,  occasionally  cutting  a  resisting  band  with 
the  scissors.  At  times  the  sac  is  very  intimately  united  with  the 
cord,  and  much  patience  is  required  to  separate  it.  One  should 
recognize  the  vas  deferens,  and  constantly  be  familiar  with  its  loca- 
tion, in  order  to  avoid  injuring  it.  In  isolating  the  sac,  one  may 
have  considerable  hemorrhage  from  the  pampiniform  plexus  of  veins, 
which  runs  along  with  the  vas  deferens,  etc.,  in  the  cord.  It  usually 
ceases,  however,  after  clamps  have  been  applied  to  the  bleeding 
points  for  a  few  minutes.  If  one  of  the  arterial  branches  which  run 
in  the  cord  is  torn,  it  will  be  necessary  to  apply  a  ligature.  One  may 
begin  the  separation  of  the  sac  from  the  cord  above  at  the  neck  of 
the  sac  and  work  downward,  toward  its  lower  part  (fundus),  or  com- 
mence at  the  fundus  and  work  upward,  toward  the  neck.     The  op- 


386  HERNIA,  ETC. 

erator  may  assist  himself  in  separating  the  sac  from  the  cord  by  in- 
cising it  in  order  to  introduce  the  finger  into  it,  and  thus  inform 
himself  of  its  limits. 

After  the  sac  has  been  completely  separated  from  the  cord,  espe- 
cially above,  about  the  neck  at  the  location  of  the  "internal  ring/' 
it  is  raised,  and  (if  not  already  incised)  is  seized  by  an  assistant  with 
the  fingers  of  both  hands,  or  with  two  artery  forceps,  and  incised 
between  them  with  the  knife.  In  incising  the  sac,  especially  if  the 
contents  are  adherent,  or  if  operating  upon  a  strangulated  hernia 
when  there  is  much  distension,  one  should  use  caution  not  to  wound 
the  parts  within.  After  the  sac  has  been  opened  the  contents  may 
be  reduced,  and,  if  there  are  no  adhesions,  this  is  very  readily  done. 
If  there  is  a  considerable  amount  of  prolapsed  omentum  in  the  sac, 
this  may  be  tied  off  with  stout  catgut  and  amputated  in  preference 
to  returning  it  to  the  abdomen.  If  the  contents  are  adherent  to  the 
sac,  they  must  be  gently  separated  before  they  can  be  reduced.  This 
can  usually  be  accomplished  with  the  finger,  taking  care  to  avoid 
tearing  the  gut,  and  ligating  any  points  that  bleed  freely.  Dense 
adhesion  bands  may  be  first  tied  double  and  then  divided  between 
the  ligatures.  If  omentum  is  adherent  within  the  sac,  it  may  be 
ligated  and  amputated.  The  contents  should  be  free,  especially  at 
the  neck  of  the  sac,  in  order  that  they  may  be  properly  reduced. 

After  the  sac  has  been  emptied  we  may  tie  it  off.  The  finger  is 
introduced  into  the  sac  and  carried  well  within  its  mouth,  and  a  catgut 
ligature  (No.  2)  thrown  around  its  neck.  As  this  ligature  is  drawn 
tight  and  tied,  one  should  feel  it  slip  over  the  end  of  the  finger, 
which  is  within  the  mouth  of  the  sac.  It  should  be  applied  about 
the  neck  of  the  sac  as  high  up  as  possible,  in  order  to  avoid  leaving 
any  pouched  portion  of  the  sac  to  invite  the  recurrence  of  the  her- 
nia. The  ligature  is  left  long  for  use  as  a  tractor,  and  the  sac  is  cut 
away,  about  one-fourth  inch  distal  from  the  ligature.  Then,  after 
a  final  examination  of  the  stump  of  the  sac,  the  ends  of  the  ligature 
are  cut  short,  and  the  stump  of  the  sac  allowed  to  retract  into  the 
abdomen.  If  the  sac  is  rather  wide-mouthed,  instead  of  simply 
surrounding  it  with  a  ligature  one  may  transfix  it  with  a  ligature 
carried  in  a  curved  needle  and  tie  double. 

The  next  step  in  the  operation  is  the  strengthening  of  the  poste- 
rior wall  of  the  inguinal  canal,  and  this  is  done  by  approximating 
the  free  edge  of  the  internal  oblique  and  transversalis  muscles  (con- 
joined tendon)  above  to  Poupart's  ligament  below.     While  this  is 


Fig.  16'!. — Bassin"  Operation  for  Inguinal  Hernia.  The  inguinal  canal  laid  open  by  splitting 
the  aponeurosis  of  the  external  oblique.  The  edges  of  the  split  aponeurosis  are  seized  with  artery 
forceps  and  drawn  aside.  Spermatic  cord  pulled  aside  with  a  loop  of  gauze  preparatory  to  suturing 
the  edge  of  the  conjoined  tendon  to  Poupart's  ligament;  CT,  edge  of  conjoined  tendon  ;  P,  edge  of 
Poupart's  ligament ;  TF,  transversalis  fascia,  which  forms  the  posterior  wall  of  the  inguinal  canal. 


Fig.  164. — The  Bassini  Operation.  The  edges  of  the  split  aponeurosis  held  aside;. with  artery 
forceps.  Conjoined  tendon  sutured  to  the  edge  of  Poupart's.  Spermatic  cord  (S.C.) 'drawn' aside 
with  gauze  loop. 


OPERATIONS  FOR  HERNIA.  387 

being  done  the  spermatic  cord  is  held  out  of  the  way  of  the  operator 
upon  a  strip  o'f  gauze,  and  the  upper  edge  of  the  divided  aponeurosis 
of  the  external  oblique,  which  is  held  in  an  artery  forceps,  is  re- 
tracted, in  order  that  the  edge  of  the  internal  oblique  and  trans- 
versalis  (conjoined  tendon)  may  be  made  out.  These  parts  can  be 
readily  seen  and  may  be  plainly  felt  by  the  finger  in  the  wound. 
Poupart's  ligament  is  likewise  freely  exposed,  when  the  lower  edge 
of  the  aponeurosis  of  the  external  oblique  is  strongly  retracted.  This 
structure  may  be  recognized  as  a  sharp,  white  band.  These  parts, 
the  conjoined  tendon  above  and  Poupart's  ligament  below,  are  now 
brought  together  with  three  to  five  interrupted  sutures  of  some  per- 
manent material,  such  as  silk-worm  gut,  silk,  silver  wire,  kangaroo 
tendon,  or  chromieized  gut.  These  sutures  are  introduced  with  a 
large,  curved  needle  grasped  in  a  needle  holder.  The  first  suture  is 
placed  externally,  just  to  the  inner  side  of  where  the  cord  emerges 
from  the  abdomen;  the  last  one  or  two  sutures,  those  nearest  the 
middle  line,  should  take  a  sufficiently  broad  bite  to  include,  together 
with  the  conjoined  tendon,  the  edge  of  the  rectus  muscle.  Ea  h 
suture  should  take  a  good,  broad  bite.  In  introducing  the  sutures 
through  Poupart's  ligament  there  is  said  to  be  some  danger,  espe- 
cially with  the  middle  sutures,  of  piercing  the  femoral  vein  with 
the  needle.  This  might  happen  if  the  needle  were  inserted  too 
deeply,  but  this  is  not  necessary,  as  a  good,  broad  bite  of  the  liga- 
ment is  easily  secured  without  introducing  the  needle  deep  enough 
to  reach  the  vein.  The  sutures  are  left  long,  and  are  not  tied  until 
all  are  introduced.  Usually  three  or  four  sutures  suffice;  sometimes 
five  are  necessary.  The  most  external  suture  should  be  placed  so  as 
to  leave  just  space  enough  for  the  cord  to  emerge  comfortably  with- 
out constriction  between  the  edge  of  the  internal  oblique  and  trans- 
versalis  above  and  Poupart's  ligament  below.  When  the  sutures  are 
tied,  the  edge  of  the  internal  oblique  and  transversalis  muscles  (eon- 
joined  tendon)  and  Poupart's  ligament  are  seen  to  be  closely  ap- 
proximated, and  in  this  way  there  is  formed  a  solid  posterior  wall 
to  the  inguinal  canal,  upon  which  the  cord  rests  when  it  is  dropped 
back  into  the  wound.  The  edges  of  the  split  aponeurosis  of  the 
external  oblique  are  now  brought  together  over  the  cord  with  a  con- 
tinuous suture  of  catgut,  simple  or  chromieized,  No.  2.  This  suture 
is  commenced  above  and  externally,  and  terminates  below  at  the  site 
of  the  former  external  abdominal  ring.  In  this  way  the  anterior  wall 
of  the  inguinal  canal  is  restored,  and  beneath  this  the  cord  is  situ- 


388  HERNIA,  ETC. 

ated.  One  should  take  care  that  the  cord  is  not  gripped  too  tightly 
between  the  posterior  and  anterior  walls  of  the  new  canal,  and  that, 
at  the  site  of  the  external  ring,  sufficient  space  is  left  for  the  cord 
to  emerge  without  danger  of  its  becoming  strangulated. 

The  wound  should  be  dry — free  from  oozing.  No  drainage  is 
necessary.  The  incision  in  the  skin  may  be  closed  with  a  continuous 
intracuticular  catgut  suture. 

In  the  female  this  operation  is  simplified  in  that  we  have  no 
spermatic  cord  to  consider;  the  round  ligament,  its  analogue,  is  sim- 
ply cut  away,  and  the  deep  sutures  which  strengthen  the  posterior 
wall  of  the  inguinal  canal  introduced  in  the  manner  described  above. 

For  a  Congenital  Hernia. — In  this  variety  of  hernia  the  sac 
is  formed  of  the  unobliterated  vaginal  process  of  the  peritoneum,  at 
the  bottom  of  which  the  testis  usually  lies.  In  some  cases  the  testis 
does  not  reach  the  bottom  of  the  scrotum  in  its  descent,  and  may 
remain  stationary,  in  any  part  of  the  inguinal  canal  or  within  the 
abdomen,  when  it  may  be  wise  to  remove  it.  The  incision  in  the 
skin  and  aponeurosis  of  the  external  oblique  are  made  as  in  the  fore- 
going operation.  After  the  inguinal  canal  has  been  laid  open,  the 
cord,  together  with  the  sac,  is  picked  up,  upon  the  finger.  The  her- 
nial sac  is  really  included  within  the  proper  sheath  of  the  cord,  in- 
fundibular process,  and  its  isolation  from  the  elements  of  the  cord 
may  be  somewhat  difficult.  The  sheath  of  the  cord  (infundibular 
process  of  the  transversalis  fascia)  must  be  incised  or  torn  through 
in  order  to  reach  the  sac.  In  separating  the  sac  we  may  commence 
above  at  the  neck  of  the  sac,  and  work  downward,  toward  the  testis. 
After  the  sac  has  been  separated  from  the  cord,  vas  deferens,  etc.,  to 
a  point  which  is  just  above  the  testis,  it  is  opened  and  its  contents 
reduced.  The  sac  is  then  cut  across,  allowing  the  lower  part,  that 
which  corresponds  to  the  testis,  to  remain  to  form  the  tunica  vag- 
inalis. The  upper  part  of  the  sac,  after  having  been  thoroughly  iso- 
lated, is  then  tied  off  at  the  point  where  it  emerges  from  the  abdo- 
men, and  the  edge  of  the  internal  oblique  and  transversalis  (con- 
joined tendon)  sutured  to  Poupart's  ligament,  as  already  described 
in  the  preceding  operation.  The  lower  part  of  the  vaginal  process 
(hernial  sac)  which  remains,  and  which  corresponds  to  the  tunica 
vaginalis  testis,  is  then  closed  with  a  continuous  catgut  suture,  so 
that  the  testis  is  shut  up  within  its  tunica  vaginalis.  The  edges  of 
the  split  aponeurosis  of  the  external  oblique  are  then  brought  to- 
gether over  the  cord,  and  the  incision  in  the  skin  closed.     If  the 


OPERATIONS  FOR  HERNIA.  389 

testis  has  been  much  handled,  it  may  be  wise  to  introduce  a  thin 
strip  of  gauze  into  the  cavity  of  the  tunica  vaginalis,  through  the 
bottom  of  the  scrotum,  for  the  purpose  of  drainage;  usually,  how- 
ever, this  is  not  necessary. 

Foe  a  Dieect  Inguinal  Heenia. — In  this  variety  of  hernia  the 
peritoneal  pouch  (hernial  sac)  does  not  enter  the  "internal  ring," 
mouth  of  the  infundibular  process,  and  work  its  way  down  along  the 
cord,  within  the  sheath  of  the  cord,  but  bulges  directly  forward,  into 
the  inguinal  canal,  to  the  inner  side  of  the  deep  epigastric  artery, 
pushing  the  transversalis  fascia,  conjoined  tendon,  and  triangular 
ligament  before  it,  and  is  found  upon  the  inner  side  of  the  spermatic 
cord  as  this  descends  through  the  inguinal  canal.  The  sac  consists 
of  a  wide-mouthed  pouch  of  peritoneum  and  subperitoneal  connect- 
ive tissue,  and,  as  it  presents  into  the  inguinal  canal,  is  covered 
by  the  transversalis  fascia,  the  conjoined  tendon,  and  the  triangular 
ligament.  It  is  also  covered  by  the  aponeurosis  of  the  external 
oblique,  superficial  and  deep  layers  of  the  superficial  fascia,  and  the 
skin.  The  mouth  of  the  sac  is  wide,  and  may  reach  from  the  external 
edge  of  the  rectus  as  far  outward  as  the  deep  epigastric  artery,  or 
even  beyond  this,  pushing  the  artery  in  front  of  it,  in  which  case 
the  artery  may  form  a  deep  groove  upon  the  sac,  and  thus  divide  't 
into  two  pouches.  Under  these  circumstances  it  may  be  necessary  to 
tie  the  artery  double  and  divide  it.  There  may  be  no  well-formed 
sac  present,  but  simply  a  wide,  conical  bulging  of  the  posterior  wall 
of  the  inguinal  canal.  In  direct  hernia  the  sac  is  readily  separated 
from  the  cord,  after  which  it  is  opened  and  its  contents  reduced.  If 
the  sac  is  very  wide-mouthed,  it  may  be  necessary  to  approximate  the 
margins  of  the  opening  with  a  catgut  suture,  and  then  cut  away  what 
remains  of  the  sac.  The  operation  is  completed  as  described  above  for 
the  oblique  variety.  While  the  cord  is  held  aside,  the  edge  of  the  con- 
joined tendon  (internal  oblique  and  transversalis  muscles)  is  sutured  to 
Poupart's  ligament.  The  cord  is  then  replaced  and  the  edges  of  the 
aponeurosis  of  the  external  oblique  sutured  over  it,  and  finally  the 
incision  in  the  skin  closed. 

Halsted's  Operation  for  Inguinal  Hernia. — The  incision  reaches 
from  a  point  5  cm.  above  and  external  to  the  site  of  the  internal 
ring,  which  is  located  half  an  inch  above  the  middle  of  Poupart's 
ligament.  It  is  carried  downward  and  inward  as  far  as  the  spine  of 
the  pubes  (site  of  the  external  ring).  This  incision  extends  through 
the  skin  and  superficial  fascia,  freely  exposing  the  aponeurosis  of 


390  HERNIA,  ETC. 

the  external  oblique  muscle  and  the  external  inguinal  ring.  All 
bleeding  points  are  clamped.  As  a  rule,  it  is  not  necessary  to  tie 
them,  as  the  hemorrhage  ceases  after  a  few  minutes'  compression. 

The  next  step  in  the  operation  consists  in  the  division  of  the 
aponeurosis  of  the  external  oblique,  the  internal  oblique  and  trans- 
versalis muscles,  and  the  transversalis  fascia.  These  structures  are 
incised  from  the  external  ring  below  to  a  point  about  2  cm.  above 
and  external  to  the  location  of  the  internal  ring,  or  farther  if  neces- 
sary, in  order  that  the  upper  and  outer  part  of  the  incision  may  ex- 
tend into  the  fleshy  part  of  the  internal  oblique  and  transversalis 
muscles.  The  vas  deferens  is  now  sought,  and,  together  with  its 
vessels,  isolated,  and  then  all  the  veins  which  accompany  the  vas 
deferens  except  two  or  three,  after  being  tied  off  above  and  below, 
are  excised.  In  this  way  the  size  of  the  cord  is  markedly  dimin- 
ished. The  remains  of  the  cord  are  now  held  to  one  side,  and  the 
isolation  of  the  hernial  sac  is  begun.  After  this  has  been  completed, 
the  sac  is  incised  and  its  contents  returned  into  the  abdomen.  When 
the  transversalis  fascia  is  incised  the  constriction  about  the  neck  of 
the  sac  disappears,  and  its  mouth,  from  a  narrow  orifice,  becomes  a 
wide-open  space,  through  which  one  may  easily  introduce  several 
fingers  or  the  whole  hand  into  the  peritoneal  cavity.  The  margins 
of  the  mouth  of  the  sac  are  now  brought  together  with  a  continuous 
or  interrupted  suture  of  catgut,  and  the  sac  below  this  suture  line 
resected.  This  step  of  the  operation  is  really  like  closing  any  ordi- 
nary opening  in  the  parietal  peritoneum.  During  the  application  of 
this  suture  a  gauze  pad  may  be  introduced,  through  the  opening  into 
the  peritoneal  cavity,  to  prevent  the  intestine  from  prolapsing  into 
the  wound.  After  the  mouth  of  the  sac,  peritoneum,  has  been  thus 
sutured  and  closed,  and  the  sac  cut  away,  we  proceed  with  the  next 
step  of  the  operation,  the  approximation  of  the  cut  edges  of  the 
several  layers  of  the  abdominal  wall.  While  this  is  being  accom- 
plished the  cord  is  raised  upon  a  hook  and  held  out  of  the  way,  well 
toward  the  outer  part  of  the  incision.  To  unite  these  parts  from  six 
to  eight  mattress  sutures  of  silk  are  required.  The  layers  which  are 
approximated  consist  above  of  the  aponeurosis  of  the  external 
oblique,  the  internal  oblique  and  the  transversalis  muscles  (con- 
joined tendon),  and  the  transversalis  fascia.  Below  they  consist  of 
Poupart's  ligament  and  the  aponeurosis  of  the  external  oblique  and 
the  transversalis  fascia,  and  in  part,  externally,  of  the  cut  edges  of 
the  internal  oblique  and  transversalis  muscles.     The  sutures  pass 


OPERATIONS  FOR  HERNIA. 


391 


through  all  these  layers.  Between  the  two  most  external  of  these 
sutures  the  -cord  emerges  through  the  abdominal  wall,  between  the  cut 
edges  of  the  internal  oblique  and  transversalis  muscles.  The  cord 
should  be  firmly  grasped  by  these  muscles,  but  not  tightly  enough 


\ 


Fig.  165.— Halsted's  Operation.  The  vas  deferens,  with  a  few  remaining 
vessels  of  the  cord,  drawn  aside  with  a  hook.  Mattress  sutures  have  been 
applied,  uniting  the  different  layers  that  have  been  cut,  including  the  apo- 
neurosis of  the  external  oblique. 


to  strangle  it.  The  cord,  as  it  emerges  through  the  abdominal  wall, 
in  its  new  position,  should  be  surrounded  by  the  fleshy  fibers  of  these 
muscles;  it  should  not  emerge  between  the  tendinous  portions  of 
the  muscles.    If  the  incision  through  the  internal  oblique  and  trans- 


392  HERNIA3  ETC. 

versalis  muscles  and  the  transversalis  fascia  has  not  heen  carried 
sufficiently  far,  in  a  direction  upward  and  outward,  to  accomplish 
this,  it  should  he  extended  farther,  so  as  to  reach  well  into  the  fleshy 
portion  of  these  muscles. 

After  the  mattress  sutures  have  been  applied  and  the  parts  al- 
ready mentioned  approximated,  the  cord  is  dropped  back  into  the 
wound  and  rests  upon  the  aponeurosis  of  the  external  oblique.  The 
edges  of  the  skin  are  then  sutured  over  the  cord  with  a  continuous 
intracuticular  suture,  thus  completing  the  operation.  The  cord  is 
transplanted  so  that  it  emerges  through  the  abdominal  wall  above 
and  external  to  the  site  of  the  "internal  ring,"  where  it  is  surrounded 
by  muscular  fibers  and  lies  just  beneath  the  skin,  instead  of  beneath 
the  aponeurosis  of  the  external  oblique. 

Operation  for  the  Radical  Cure  of  Femoral  Hernia.  —  Femoral 
hernia  descends  through  the  crural  canal  upon  the  inner  side  of  the 
femoral  vein,  and  presents  in  the  thigh,  just  below  Poupart's  liga- 
ment. In  order  to  expose  the  sac  of  the  hernia  an  incision  is  made 
below  and  parallel  with  Poupart's  ligament,  the  middle  of  the  in- 
cision being  over  the  center  of  the  tumor.  This  incision  is  carried 
through  the  skin  and  subcutaneous  fatty  tissue  and  the  deep  layer 
of  the  superficial  fascia  (cribriform)  down  to  the  sac.  Instead  of 
being  placed  parallel  with  Poupart's  ligament,  the  incision  may  be 
made  in  an  oblique  direction  from  above  downward. 

The  sac  is  now  isolated,  and  separated  from  the  adjoining  parts 
up  to  and  beyond  the  level  of  Poupart's  ligament.  Special  care  is 
required  in  separating  the  sac  on  the  side  which  adjoins  the  femoral 
vein.  After  the  sac  has  been  thoroughly  isolated  it  is  opened  and 
the  contents  reduced.  The  sac  is  then  twisted  and  tied  off  as  high  up 
as  possible.  It  may  be  surrounded  with  a  simple  catgut  ligature,  or 
it  may  be  transfixed  and  tied  double.  The  portion  of  the  sac  below 
the  ligature  is  then  cut  away,  the  ends  of  the  ligature  cut  short,  and 
the  stump  of  the  sac  pushed  back  beyond  Poupart's  ligament  into 
the  abdomen. 

We  are  now  ready  to  close  the  orifice  through  which  the  hernia 
descended  into  the  thigh.  We  should  first  recognize  the  margins  of 
this  orifice,  the  crural  ring.  This  is  bounded  above  by  Poupart's 
ligament;  internally  by  the  edge  of  Gimbernat's  ligament;  below 
by  the  fascia  that  covers  the  pectineus  muscle,  the  upper,  thickened 
portion  of  which  is  called  the  pubic  ligament  of  Cooper,  and  which  ex- 
tends from  Gimbernat's  ligament  to  the  pectineal  eminence;  externally 


Fig.  166. — Operation  for  Femoral  Hernia.     FV,  femoral  vein.     Poupart's  ligament jhas  been 
sutured  to  the  upper  part  of  the  fascia  that  covers  the  pectineus  muscle. 


SPERMATIC  CORD,  SCROTUM,  ETC.  393 

it  is  bounded  by  the  femoral  vein.  The  edge  of  the  falciform  process 
should  also  be  recognized,  and  likewise  the  internal  saphenous  vein, 
where  it  joins  the  femoral.  The  crural  ring  is  obliterated  by  sutur- 
ing the  lower  edge  of  Poupart's  ligament  to  the  fascia  which  covers 
the  pectineus  muscle;  i.e.,  to  that  part  of  it  which  covers  the  upper 
part  of  the  pectineus — the  pubic  ligament  of  Cooper.  The  stitches 
should  be  of  silk,  and  should  be  introduced  with  a  short,  full-curved 
needle.  The  first  suture  catches  Poupart's  ligament  just  external  to 
its  attachment  to  the  pubic  spine,  and  should  take  a  good  bite.  After 
the  needle  is  drawn  through  Poupart's  ligament  is  pulled  upward  and 
backward  with  a  blunt  hook  in  order  to  permit  the  needle  to  catch 
the  pectineal  fascia  as  high  up  under  Poupart's  ligament  as  pos- 
sible; i.e.,  near  the  ilio-pectineal  line,  from  which  the  pectineus  mus- 
cle arises.  Half  a  centimeter  external  to  this  suture  a  second  suture 
is  introduced  in  a  similar  manner,  and  then,  at  a  distance  of  another 
half-centimeter,  a  third  suture.  These  three  sutures  suffice  to  close 
the  opening.  The  third  and  last  suture  is  located  about  1  cm.  to  the 
inner  side  of  the  femoral  vein.  When  these  sutures  are  tied,  the 
lower  edge  of  Poupart's  ligament  and  the  pectineal  fascia  (the  thick- 
ened portion,  high  up  near  the  origin  of  the  pectineus  muscle  from 
the  ilio-pectineal  line)  are  approximated,  and  the  crural  ring  is  thus 
obliterated.  The  opening  in  the  skin  is  closed  in  the  usual  way.  No 
drainage  is  required. 

THE  SPERMATIC  CORD,  SCROTUM,   ETC. 

The  Spermatic  Cord. — The  spermatic  cord  descends  through  the 
inguinal  canal,  emerging  at  the  external  inguinal  ring.  As  it  emerges 
from  the  external  ring  it  lies  just  beneath  the  integument  in  the  sub- 
cutaneous fat,  and  descends  into  the  scrotum,  where  it  is  joined  to 
the  posterior  border  of  the  testis.  It  is  about  as  thick  around  as  the 
little  finger,  and  is  made  up  of  a  bundle  of  structures,  the  vas  deferens, 
the  artery  of  the  vas  deferens,  and  the  cremasteric  artery,  their  corre- 
sponding veins,  the  spermatic  artery,  and  a  tortuous  venous  plexus, 
the  pampiniform.  The  vas  deferens,  the  efferent  duct  of  the  testis, 
occupies  the  posterior  part  of  the  cord.  The  vas  deferens  is  about 
as  big  around  as  a  goose  quill,  has  a  firm  feel,  and  may  be  readily 
recognized  as  it  is  rolled  between  the  fingers.  The  artery  of  the  vas 
deferens  ramifies  upon  the  vas  deferens,  supplies  it,  and  anastomoses 
below  with  the  spermatic  artery.    The  cremasteric  artery  is  distributed 


394  HERNIA,  ETC. 

to  the  constituents  of  the  cord,  and  supplies  its  sheath.  The  spermatic 
artery  is  given  off  from  the  aorta;  it  supplies  the  testis  and  has  a 
strong  current  of  blood.  The  pampiniform  plexus  is  a  tortuous,  in- 
tercommunicating plexus  of  venous  channels  that  accompanies  the 
other  elements  of  the  cord.  Through  this  plexus  the  blood  is  returned 
from  the  testis.  The  vessels  of  the  pampiniform  plexus  join  together 
above  to  form  the  spermatic  vein.  This  vein  upon  the  right  side 
enters  the  vena  cava  directly;  upon  the  left  side  it  empties  into  the 
renal  vein,  so  that  the  venous  return  on  the  left  side  is  less  direct 
than  upon  the  right  side.  Varicocele  is  usually  found  upon  the  left 
side. 

As  these  structures  traverse  the  inguinal  canal  they  are  all  con- 
tained within  the  infundibular  process,  which  serves  to  bind  them 
together  into  a  single  bundle  and  which  forms  the  real  fibrous  sheath 
of  the  cord,  the  fascia  propria.  Descending  upon  the  cord  is  a  series 
of  looped,  muscular  fibers,  each  joined  to  the  other  by  an  intervening 
thin  fascia.  These  are  the  cremaster  muscle  and  fascia.  These  fibers, 
that  form  the  cremaster  muscle,  are  derived  from  the  lower  border  of 
the  internal  oblique. 

As  the  cord  emerges  from  the  external  inguinal  ring,  the  deep 
layer  of  the  superficial  fascia  (spermatic  fascia),  which  is  attached  to 
the  pillars  or  margins  of  the  ring,  is  continued  down  upon  the  cord, 
inclosing  it  and  forming  one  of  its  investments. 

The  Scrotum. — The  scrotum  is  a  pouch  with  two  compartments, 
one  on  each  side,  separated  by  a  median  septum.  It  consists  of  sev- 
eral layers,  from  without  inward.  The  skin  is  redundant,  corrugated, 
and  wrinkled.  Beneath  the  skin  is  the  dartos.  The  dartos  is  a  loose, 
reddish,  contractile  layer,  which  is  found  immediately  beneath  the 
skin.  It  contains  some  muscular  fibers,  and  is  continuous  behind  with 
the  two  layers  of  the  superficial  perineal  fascia,  and  laterally  with 
the  same  layers  in  the  groin.  It  sends  a  septum  into  the  scrotum, 
which  divides  it  into  its  two  halves.  Beneath  the  dartos  is  the  cre- 
master muscle  and  fascia,  and  beneath  this  the  infundibular  fascia, 
and,  finally,  most  internal,  the  parietal  layer  of  the  tunica  vaginalis. 

The  Testes. — The  testes  are  situated  in  the  scrotum,  each  sus- 
pended by  its  spermatic  cord.  They  are  partially  invested  by  a  closed, 
serous  sac,  the  tunica  vaginalis.  This  is  the  unobliterated  part  of  the 
vaginal  process  of  the  peritoneum,  the  peritoneal  pouch  that  accom- 
panies the  testis  in  its  descent  from  the  abdomen  into  the  infundibular 
process,  the  scrotum,  before  birth. 


CT,  cavity  of  the  tunica 
vaginalis  testis. 

CV,  cremaster  artery  and 
artery  of  the  vas  deferens 
and  their  corresponding 
veins,  all  in  close  proxim- 
ity to  the  vas  deferens. 

//?,  internal  inguinal  ring — 
the  mouth  of  the  original 
infundibular  process — 
through  which  the  struct- 
ures that  constitute  the 
cord  escape  (the  infundib- 
ular process  becomes  con- 
tracted around  the  elements 
of  the  cord  and  forms  their 
proper  sheath — the  fascia 
propria  [red  line]). 

P,  peritoneum  that  lines  the 
interior  of  the  abdomen. 

S,  symphysis  pubis. 

SAV,  spermatic  artery  and 
veins  (below,  along  the 
course  of  the  cord,  the 
spermatic  veins  consist  of 
a  plexus  of  intercommuni- 
cating branches — the  pam- 
piniform plexus). 

TF,  transversalis  fascia. 

VD,  vas  deferens. 

VP>  remains  of  the  obliter- 
ated vaginal  process  of  per- 
itoneum that  accompanies 
the  testis  in  its  descent  into 
the  scrotum  (the  arrow 
indicates  the  site  of  the 
former  opening  or  mouth 
of  this  process). 


Fig.  107. — Spermatic  Cord. 


AP 

Fig.  168. — Cross  Section  of  Spermatic   Cord. 


AP,  spermatic  artery  and 
pampiniform  plexus. 

FP,  fascia  propria  (sheath  of 
the  cord  and  original  in- 
fundibular process). 

VD,  vas  deferens  surrounded 
closely  by  the  cremaster 
artery  and  artery  of  the 
vas  deferens  and  their 
corresponding  veins. 

VP,  remains  of  the  obliter- 
ated vaginal  process. 


Fig.  169. — Exposure  of  Spermatic  Cord.  The  spermatic  cord  has  been  hooked 
up  out  of  the  incision  upon  the  finger,  and  its  sheath  incised  preparatory  to  sepa- 
rating the  vas  deferens  and  adjoining  vessels  from  the  other  structures  of  the  cord. 


OPERATIONS  UPON  SPERMATIC  CORD,  SCROTUM,  ETC.         395 

If  we  cut  through  the  anterior  wall  of  the  scrotum,  through 
these  various  layers,  we  enter  the  cavity  of  the  tunica  vaginalis,  which 
contains  normally  a  small  quantity  of  serous  fluid.  The  testis  pre- 
sents into  this  cavity,  being  partially  invested  by  the  visceral  layer 
of  the  tunica  vaginalis.  The  posterior  border  of  the  testis  is  not 
covered  by  the  tunica  vaginalis,  and  is  excluded  from  the  cavity  of 
the  tunica  vaginalis. 

Along  the  posterior  border  of  the  testis  is  the  epididymis.  It 
surmounts  the  testis  above  like  a  cap.  It  has  a  body,  an  upper,  larger 
portion,  the  globus  major;  and  a  lower,  smaller  portion,  the  globus 
minor.  The  vas  deferens  is  the  continuation  of  the  epididymis.  It 
commences  at  the  lower  end  of  the  globus  minor,  and,  passing  upward 
along  the  posterior,  inner  border  of  the  testis,  is  found  in  the  pos- 
terior part  of  the  spermatic  cord,  passing  through  the  "internal  ring" 
into  the  abdomen.  Within  the  abdomen  it  dips  down  into  the  pelvis, 
to  terminate  between  the  base  of  the  bladder  and  the  rectum,  where 
it  joins  with  the  duct  of  the  seminal  vesicle  of  the  corresponding  side 
to  form  the  ejaculatory  duct. 

The  Ejaculatory  Ducts. — The  ejaculatory  ducts  are  two  in  num- 
ber, one  on  each  side.  They  are  about  three-fourths  inch  long,  pass 
forward  through  the  prostate  gland,  one  on  either  side  of  the  middle 
line,  between  the  middle  and  lateral  lobes  of  the  prostate,  and  open 
upon  the  floor  of  the  prostatic  urethra. 

OPERATIONS  UPON  THE  SPERMATIC  CORD,  SCROTUM,  ETC. 

For  Varicocele.  Open  Opekation. — An  incision  is  made,  about 
one  and  one-half  inches  long,  into  the  upper  part  of  the  front  of  the 
scrotum,  commencing  just  below  the  spine  of  the  pubes,  and  passing 
through  the  skin  into  the  subcutaneous  fatty  layer.  This  incision 
can  be  made  by  pinching  up  the  skin  and  transfixing  it  with  a  sharp- 
pointed  knife  or  by  cutting  it  with  the  scissors.  The  cord  is  then 
hooked  up,  upon  the  finger,  out  of  the  loose,  fatty  layer  in  which  it 
lies,  and  with  one  or  two  strokes  of  the  knife  its  sheath  (the  spermatic 
fascia  and  the  fascia  propria)  is  opened.  The  vas  deferens  is  sought 
and  recognized,  and  together  with  the  immediately  adjacent  veins  is 
separated  from  the  other  parts  of  the  cord.  This  is  done  with  the 
fingers,  holding  the  vas  deferens  and  the  several  adjacent  veins,  which 
are  to  be  allowed  to  remain  securely  between  the  finger  and  thumb 
of  the  left  hand,  while  the  work  of  separating  the  other  structures  of 


396 


HEKNIA,  ETC. 


the  cord,  veins  of  the  pampiniform  plexus  and  the  spermatic  artery, 
from  the  vas  deferens,  may  be  accomplished  with  the  fingers  of  the 
right  hand. 

After  the  vas  deferens,  together  with  the  several  immediately 
adjacent  veins,  has  been  isolated  for  a  distance  varying  from  one  to 
two  inches,  depending  upon  the  laxness  of  the  scrotum  and  the  length 
of  the  cord,  etc.,  a  double  catgut  ligature  is  passed  with  an  artery 
forceps  and  then  cut  so  that  we  have  two  ligatures.  These  ligatures, 
which  surround  all  those  structures  of  the  cord  that  have  been  sepa- 
rated from  the  vas  deferens,  etc.,  are  tied,  one  above  and  the  other 


Fig.  170. — Varicocele.  The  vas  deferens  and  adjoining  vessels  (.4)  have 
been  separated  from  the  other  structures  of  the  cord — from  the  spermatic 
artery  and  pampiniform  plexus  (B).  Ligatures  have  been  tied  about  B  above 
and  below  preparatory  to  excising  the  intervening  portion. 


below.  The  portion  intervening  is  excised  with  the  scissors,  not  too 
close  to  the  ligatures,  and  the  ends  of  the  ligatures,  which  have  been 
purposely  left  long,  are  then  tied  together,  in  this  way  bringing  the 
ends  of  both  stumps  into  apposition.  The  ends  of  these  two  portions 
may  be  still  further  secured  by  one  or  two  catgut  sutures,  which 
should  take  a  good  bite  through  the  whole  thickness  of  each  stump. 

The  portion  of  the  cord  which  is  stripped  away  from  the  vas 
deferens,  and  which  is  ligated  and  excised,  is  composed  of  all  the 
veins  of  the  pampiniform  plexus  and  the  spermatic  artery.  When 
the  vas  is  isolated,  the  artery  of  the  vas  deferens,  which  anastomoses 


OPERATIONS  UPON  SPERMATIC  CORD,  SCROTUM,  ETC.         397 

below  with  the  spermatic  artery,  and  the  cremasteric  artery,  together 
with  their  -corresponding  veins,  go  with  it;  these  vessels  are  there- 
fore not  interfered  with,  and  they  are  sufficient  to  provide  for  the 
nutrition  of  the  testis  after  the  pampiniform  plexus  and  the  sper- 
matic artery  have  been  ligated. 

For  the  ligatures,  plain  catgut,  not  too  thick  (No.  1  or  2)  may 
be  used,  and  special  care  should  be  taken  to  apply  the  upper  ligature 
securely  that  it  may  not  slip,  as  this  would  result  in  a  very  free  hem- 
orrhage from  the  end  of  the  spermatic  artery. 

In  this  operation  one  not  only  ties  off  the  veins  of  the  pam- 
piniform plexus,  but  also  shortens  the  cord,  and  thus  draws  the  testis 
up,  a  result  which  is  much  to  be  desired.  Before  closing  the  incision 
in  the  skin  all  bleeding  points  should  be  clamped  and  ligated  or 
twisted,  and  the  wound  should  be  dry.  The  edges  of  the  incision 
in  the  skin  are  brought  together  with  a  continuous  stitch  of  catgut, 
which  may  be  intracuticular. 

For  Hydrocele. — A  condition  in  which  the  tunica  vaginalis  is 
distended  with  serous  fluid.  The  testis  is  usually  found  in  the  lower, 
back  part  of  the  sac,  the  fluid  being  collected  above  and  in  front 
of  it. 

Puncture  and  Injection. — This  is  suitable  for  simple  cases, 
and  for  those  where  tapping  has  not  been  previously  resorted  to. 
The  scrotum  is  grasped  in  the  left  hand,  in  order  to  make  it  tense 
and  to  steady  it.  A  fine  needle,  attached  to  a  hypodermic  syringe,  is 
introduced  through  the  anterior  wall  of  the  scrotum,  and  a  small 
quantity  of  the  fluid  drawn  off,  both  for  the  purpose  of  confirming 
the  diagnosis  and  to  demonstrate  the  fact  that  the  needle  is  in  the 
cavity  of  the  tunica  vaginalis.  The  hypodermic  needle  is  left  in  situ, 
its  end  free  in  the  cavity  of  the  tunica  vaginalis.  A  fairly  large 
trochar  is  then  thrust  through  the  bottom  of  the  scrotum  rather 
toward  the  front,  and  in  an  upward  direction  into  the  cavity  of  the 
tunica  vaginalis.  In  doing  this  one  should  remember  that  the  testis 
occupies  the  lower  back  part  of  the  sac.  With  the  trochar  in  the  cavity 
of  the  tunica  vaginalis  one  should  be  able  with  it  to  touch  the  hypo- 
dermic needle  previously  introduced  into  the  sac  above.  The  sac  is 
allowed  to  empty  itself  through  the  cannula,  and  this  is  then  with- 
drawn. 

The  barrel  of  the  hypodermic  syringe  is  now  filled  with  the 
fluid  to  be  injected.  Twenty  minims  of  a  95-per-cent.  carbolic-acid 
solution  may  be  used,  with  satisfactory  results,  for  this  purpose. 


398 


HERNIA,  ETC. 


This  is  thrown  into  the  cavity  of  the  tunica  vaginalis  through  the 
hypodermic  needle,  and  then  this  needle  is  also  withdrawn.  The 
fluid  that  has  been  thus  introduced  into  the  cavity  of  the  tunica 
vaginalis  is  distributed  over  the  whole  cavity  by  manipulating  the 
scrotum.  The  punctures  made  by  the  instruments  are  covered  over 
with  a  thin  coat  of  collodion,  and  a  very  thin  film  of  absorbent 
cotton. 


Fig.  171. — Hydrocele,  Tapping.  CTV,  cavity  of  the  tunica  vaginalis  testis; 
T,  testis;  V,  vas  deferens.  Hypodermic  needle  introduced  into  the  upper  part 
of  the  sac;  trochar  cannula  into  the  lower  part. 


This  operation  is  usually  followed  by  some  effusion  into  the  sac, 
and  with  but  little  or  no  pain.  After  a  few  days'  rest  in  bed  with 
the  scrotum  supported,  these  symptoms  subside.  The  operation  is 
not  painful,  but  the  part  where  the  trochar  is  to  be  introduced  may 
be  anaesthetized  with  ethyl  chloride  if  desired. 

Open  Operation  (Volkmann). — This  operation  is  suitable  for 
those  cases  that  have  already  been  tapped  many  times  or  where  the 
operation  previously  described  has  been  tried  and  has  failed. 


Fig.  172.— Volkmann  Operation  for  Hydrocele.     Edge  of  tunica  vaginalis  sutured 
to  the  edges  of  the  skin  incision. 


OPERATIONS  UPON  SPERMATIC  CORD,  SCROTUM,  ETC.         399 

The  scrotum  is  grasped  by  an  assistant  in  order  to  make  it  tense 
and  to  steady  it.  An  incision  is  made  through  the  anterior  wall  of 
the  scrotum,  opening  into  the  cavity  of  the  tunica  vaginalis.  The 
length  of  the  incision  depends  upon  the  size  of  the  tumor,  hut  is 
usually  two  or  three  inches.  When  the  tunica  vaginalis  has  been 
opened,  and  while  the  fluid  is  escaping,  the  edge  of  the  parietal  layer 
of  the  tunica  vaginalis — i.e.,  the  inner  lining  of  the  scrotal  sac — is 
seized  on  either  side  with  an  artery  forceps,  and  with  the  finger  this 
is  torn  away  from  its  attachment  to  the  inner  aspect  of  the  scrotum, 
and  excised  in  part  with  the  scissors.  If  the  tumor  has  been  very 
large,  it  will  be  necessary  to  excise  more  of  the  tunica  vaginalis  than 
if  the  tumor  is  smaller.  The  tunica  vaginalis  may  be  much  thick- 
ened. In  trimming  away  this  redundant  portion  of  the  tunica  vag- 
inalis one  must  take  care  to  leave  enough  to  conveniently  cover  the 
testis  and  also  avoid  cutting  into  the  epididymis.  It  is  rather  better 
to  excise  too  little  than  too  much  of  the  tunica  vaginalis.  After  this 
part  of  the  operation  has  been  done  the  edge  of  that  portion  of  the 
tunica  vaginalis  which  remains  is  fixed  to  the  corresponding  edge 
of  the  skin  incision  all  around  with  a  continuous  or  with  several 
interrupted  fine  catgut  sutures.  Then,  with  a  wad  of  cotton  on  a 
stick,  the  whole  interior  of  what  remains  of  the  tunica  vaginalis,  in- 
cluding that  covering  the  testis,  is  swabbed  out  with  95-per-cent. 
carbolic  acid.  The  cavity  is  then  loosely  packed  with  sterile  gauze. 
The  strips  should  reach  well  down  into  the  deepest  recesses  of  the 
cavity,  but  the  packing  should  not  be  tight.  A  loose  dressing  is 
applied,  which  may  be  held  in  place  by  a  T-bandage.  The  packing 
should  be  removed  at  the  end  of  forty-eight  hours,  simply  retaining 
a  strip  in  the  opening  in  the  skin,  and  the  parts  allowed  to  granulate. 
If  too  much  of  the  tunica  has  been  removed,  there  will  be  too  much 
inversion  of  the  skin,  and  this  will  delay  the  healing  process. 

Excision  of  the  Tunica  (von  Bergmann). — After  the  tunica 
vaginalis  sac  has  been  opened  and  its  contents  evacuated,  the  parietal 
layer  of  the  tunica  vaginalis  is  seized  and  stripped  away  from  its 
attachment  bluntly  with  the  fingers  as  far  back  as  the  posterior  bor- 
der of  the  testis,  or  rather  epididymis,  and  then  excised  in  its  en- 
tirety with  the  scissors.  After  all  bleeding  has  been  controlled  with 
forceps  and  ligatures,  the  wound  in  the  skin  is  closed  with  sutures, 
without  any  drainage  whatever.  As  a  rule,  the  skin  incision  heals 
by  first  intention,  and  the  patient  is  able  to  be  around  in  about  twelve 
days. 


400  HERNIA,  ETC. 

This  method  is  very  satisfactory,  and  is  especially  applicable  to 
those  cases  where  the  tunica  vaginalis  is  excessively  redundant  after 
the  evacuation  of  a  large  hydrocele,  or  when  the  tunica  is  markedly 
thickened. 

Betkoveesion  of  the  Tunica  Vaginalis. — This  method  has 
been  variously  ascribed  to  Jaboulay,  Doyen,  Garampozzi,  and  Win- 
kelmann.  An  incision  is  made  in  the  front  of  the  scrotum,  usually 
about  two  inches  in  length,  into  the  cavity  of  the  tunica.  Through 
this  opening  the  fluid  contents  of  the  distended  tunica  vaginalis 
escape,  and  the  testis  is  then  drawn  forward  out  of  the  scrotum. 


Fig.  173.— Hydrocele.     Retroversion  of  the  tunica  vaginalis.    The  tunica  has  heen 
turned  back  beyond  the  epididymis  and  fixed  there  by  sutures. 


As  the  testis  is  drawn  forward  out  of  the  scrotum,  the  vaginal 
layer  of  the  tunica  is  reflected  backward, — turned  inside  out,  as  it 
were, — so  that  the  opening  in  the  parietal  layer  of  the  tunica, 
through  which  the  testis  bas  been  drawn,  gets  to  lie  behind  the  testis, 
encircling  the  cord  and  covering  over  the  epididymis,  and  in  this 
position  it  is  fixed  by  joining  its  edges  together  with  several  catgut 
sutures  so  that  it  may  not  again  slip  forward  over  the  testis.  The 
edges  of  the  incision  in  the  scrotum  are  now  sufficiently  detached  to 
allow  the  integument  of  the  scrotum  to  be  drawn  forward  and  cover 


Fig.  17-1. — Castration.  Cord  has  been  divided.  The  end  of  the  lower  por- 
tion grasped  with  an  artery  forceps.  A  ligature  has  been  tied  around  the  end 
of  the  upper  stump.  It  will  be  noticed  that  the  vas  deferens  is  not  included  in 
the  ligature. 


OPERATIONS  UPON  SPERMATIC  CORD,  SCROTUM,  ETC.         401 

over  the  testis  and  reflected  tunica  vaginalis,  and  they  are  thus  united 
to  each  other  without  drainage,  in  this  way  completing  the  operation. 

The  result  of  this  operation  is  that  the  free  secreting  surface  of 
the  tunica  vaginalis  which  has  been  turned  inside  out  is  brought  into 
contact  with  the  raw  internal  wound  surface  of  the  scrotum,  to  which 
it  becomes  united,  effecting  the  cure. 

If  the  tunica  vaginalis  is  very  redundant  after  evacuating  a 
large  hydrocele,  a  part  of  the  tunica  may  be  excised  with  the  scissors, 
leaving  just  enough  to  complete  the  operation  as  described  above;  but 
for  those  very  large  hydroceles,  and  those  with  a  markedly  thickened 
tunica,  the  von  Bergmann  is  probably  the  more  satisfactory  opera- 
tion. 

Castration  (Extirpation  of  the  Testis). — An  incision,  about  two 
inches  long,  is  made  upon  the  front  of  the  upper  part  of  the  scrotum 
through  the  skin  and  fat,  commencing  at  a  point  just  below  the  ex- 
ternal ring — the  spine  of  the  pubes.  If  operating  for  malignant  dis- 
ease, and  if  the  skin  is  involved,  the  incision  may  be  arranged  so  as 
to  circumscribe  that  part  of  the  skin  which  is  involved.  In  the  upper 
part  of  the  incision  the  cord  is  found,  and  hooked  up,  upon  the  finger, 
and  just  below  the  point  where  it  emerges  from  the  external  ring  its 
sheath  is  incised  with  the  point  of  the  knife.  The  vas  deferens  is  then 
recognized,  and  should  be  separated  from  the  rest  of  the  cord.  A 
catgut  ligature  is  then  passed  about  those  parts  of  the  cord  which 
have  been  separated  from  the  vas  deferens,  and  tied  so  tightly 
that  it  cannot  slip  off.  This  ligature  should  include  all  the  elements 
of  the  cord  except  the  vas  deferens.  The  ends  of  this  ligature  are 
left  long,  to  serve  as  a  tractor;  the  cord,  including  the  vas  deferens, 
is  then  divided  with  the  scissors,  at  least  half  an  inch  below,  distal 
to  the  ligature.  Before  dividing  the  cord  it  is  grasped,  below  the 
point  at  which  it  is  to  be  divided,  with  an  artery  clamp.  The  cord 
having  been  divided,  the  lower  end,  that  which  is  held  in  the  grasp 
of  the  artery  forceps,  together  with  the  testis,  and  including  the  tunica 
vaginalis,  is  enucleated  from  the  scrotum,  usually  without  opening 
into  the  cavity  of  the  tunica  vaginalis,  and  almost  entirely  by  blunt 
dissection.  Where  the  knife  or  scissors  is  used  to  assist  in  this  enu- 
cleation one  should  take  care  not  to  cut  through  the  septum  into 
the  other  half  of  the  scrotum,  and  one  should  also  avoid  button-holing 
the  skin. 

After  the  testis  has  been  enucleated  we  return  to  the  stump  of 
the  cord.     This  may  be  brought  into  view  by  drawing  upon  the  liga- 


402  HERNIA,  ETC. 

ture,  which  was  left  long  to  serve  as  a  tractor,  and  if  there  is  no  bleed- 
ing this  ligature  may  be  cut  short  and  the  stump  of  the  cord  allowed 
to  retract  up  into  the  inguinal  canal.  Should  there  be  any  bleeding 
points,  these  may  be  clamped  and  ligated.  One  should  avoid  includ- 
ing the  stump  of  the  vas  deferens  in  the  ligature,  as  it  may  result  in 
disagreeable  symptoms;   e.g.,  colicky  pain,  etc. 

The  wound  is  large,  and  may  be  closed  with  catgut  sutures;  in 
most  cases,  however,  it  is  well  to  place  a  drain  in  the  lower  end  of  the 
wound.  If  operating  for  tuberculosis,  the  cord  should  be  divided  as 
high  up  as  one  can  reach. 


PART   VIII. 

THE  URINARY  SYSTEM. 


THE   KIDNEYS. 

The  Surgical  Anatomy  of  the  Kidney. — One  kidney  may  be  absent 
in  apparently  normal  subjects,  the  left  more  frequently  than  the  right. 
This  is  said  to  occur  once  in  about  two  thousand  four  hundred  sub- 
jects. Absence  of  one  kidney  has  been  met  with  twice  in  five  hundred 
subjects  in  the  writer's  experience.  When  one  kidney  is  absent  that 
which  is  present  is  usually  larger  and  assumes  the  function  of  both 
kidneys. 

There  may  be  two  kidneys  present,  joined  together  below  or 
above,  horseshoe  kidney,  or  both  above  and  below,  either  with  con- 
nective tissue  or  kidney  tissue.  This  condition  is  met  with  about 
once  in  one  thousand  subjects. 

At  times  the  kidney  becomes  loosened  in  its  bed,  and  may  become 
dislodged,— movable  kidney, — or  it  may  be  provided  with  a  nearly 
complete  peritoneal  covering  and  mesentery  and  enjoy  a  considerable 
range  of  motion,  when  it  is  called  "floating,  or  wandering,"  kidney. 

The  kidneys  lie  in  the  upper  back  part  of  the  abdomen,  one  on 
each  side  of  the  vertebral  column,  from  the  twelfth  dorsal  to  the  third 
lumbar  vertebra.  They  are  extraperitoneal  organs,  being  covered  by 
peritoneum  upon  their  anterior  surface  only. 

The  kidneys  are  provided  with  a  fibrous  capsule,  which  is  usually 
very  thin  and  closely  adherent  to  the  organ.  They  are  lodged  within 
a  bed  of  loose  fat  and  connective  tissue,  out  of  which  they  may  be 
readily  enucleated.  The  anterior  surface  of  the  kidney  is  directed  for- 
ward and  outward,  and  is  covered  by  the  peritoneum.  The  descending 
part  of  the  duodenum  lies  in  front  of  the  right  kidney,  the  pancreas 
in  front  of  the  left  kidney. 

The  upper  part  of  the  posterior  surface  of  the  kidney  is  separated 
from  the  eleventh  and  twelfth  ribs  by  the  diaphragm  and  pleura;  the 
lower  part  of  the  posterior  surface  of  the  kidney  rests  upon  the  quad- 
ratus  lumborum  muscle,  which  is  covered  by  the  anterior  layer  of  the 
lumbar  fascia.  Normally  the  upper  half  of  the  kidney  lies  above  the 
twelfth  rib,  and  the  lower  half  below  the  twelfth  rib. 

(403) 


404  URINARY  SYSTEM. 

The  inner  border  of  the  kidney  is  concave,  and  is  directed  toward 
the  psoas  muscle  and  the  vertebral  column;  the  inner  border  of  the 
kidney  really  rests  upon  the  edge  of  the  psoas  muscle,  and  the 
kidney  is  thus  tilted  somewhat  outward.  Corresponding  to  the  inner 
border  of  the  kidney  are  the  artery  and  vein  and  the  ureter.  At  the 
hilum  the  relation  of  these  structures  from  before  backward  is  vein, 
artery,  and  ureter;  upon  the  left  side  the  artery  lies  above  the  vein, 
and  upon  the  right  side  the  vein  lies  above  the  artery;  upon  both  sides 
the  ureter  is  the  lowest  of  the  three  structures. 

The  outer  border  of  the  kidney  is  rounded  and  convex,  and  is 
related,  the  right,  with  the  ascending  colon,  and  the  left  with  the 
descending  colon.  The  colon  really  lies  a  little  in  front  of  the  kidney, 
as  well  as  to  its  outer  side. 

The  upper  end  of  the  kidney  is  covered  by  the  suprarenal  cap- 
sule, which  sits  upon  it  like  a  cap.  The  upper  end  of  the  right  kidney 
is  in  close  relation  with  the  under  surface  of  the  liver.  The  upper 
end  of  the  left  kidney  lies  close  to  the  spleen.  The  lower  end  of  the 
kidney  reaches  to  within  one  or  two  inches  of  the  crest  of  the  ilium. 

The  right  kidney  is  located  about  one  inch  lower  than  the  left, 
and  this  is  due  to  the  presence  of  the  liver  upon  the  right  side;  the 
right  kidney  is,  therefore,  more  accessible  than  the  left,  and  this  is 
also  the  one  which  is  more  frequently  movable  and  the  object  of 
operative  measures. 

OPERATIONS  UPON  THE  KIDNEY. 

Nephropexy. — Suture  or  fixation  of  a  movable  or  floating  kidney. 

A  movable  kidney  is  one  that  enjoys  a  limited  range  of  motion 
in  the  posterior  part  of  the  abdomen,  but  which  does  not  leave  the 
lumbar  region.  A  floating  kidney  is  one  that  is  more  or  less  com- 
pletely invested  with  a  peritoneal  coat  and  provided  with  a  more 
or  less  complete  mesonephron,  and  therefore  enjoys  a  considerable 
range  of  motion,  and  is  capable  of  leaving  the  lumbar  region  entirely. 

In  operating  upon  the  kidney  through  the  lumbar  incision  the 
patient  may  be  placed  prone  upon  the  table  with  an  Edebohls  cushion 
under  the  abdomen,  or  he  may  rest  upon  the  side  of  the  body  corre- 
sponding to  the  kidney  which  is  not  the  object  of  operation,  with 
the  knees  and  thighs  somewhat  flexed  and  the  front  of  the  body 
turned  toward  the  table.  In  this  latter  position  the  patient  is 
steadied  with  sand  bags  placed  against  the  chest  and  abdomen;   an- 


OPERATIONS  UPON  THE  KIDNEY. 


405 


other  sand  bag  or  cushion  may  be  placed  between  the  lower  part  of 
the  side  of  the  chest  and  the  table,  with  the  idea  of  increasing  the 
space  between  the  lower  border  of  the  twelfth  rib  and  the  crest  of 
the  ilium  upon  the  side  of  operation. 

It  is  important  that  the  abdomen  be  relaxed  in  order  that  the 
assistant  during  the  operation  may  be  able  through  the  abdominal  wall 
to  push  the  kidney  upward  toward  the  incision  in  the  loin.  Probably 
the  most  satisfactory  position  is  with  the  patient  lying  prone  upon  the 


^ 


Fig.   175.— Incision  to   Expose  Kidney.     A,   along  the  edge  of  the  erector 
spina?.    A',  additional  incision  along  the  edge  of  the  last  rib. 


table  with  the  Edebohls  cushion  under  the  abdomen,  especially  if  both 
kidneys  are  to  be  exposed  during  the  operation. 

The  incision  corresponds  to  the  outer  border  of  the  erector 
spinas  muscle,  commencing,  above,  just  below  the  twelfth  rib,  about 
two  and  a  half  inches  from  the  middle  line  (spinous  processes);  it 
passes  downward,  curving  somewhat  outward,  and  terminates  just 
above  the  crest  of  the  ilium.  This  incision  should  extend  through 
the  skin  and  subcutaneous  fat  down  to  the  surface  of  the  latissimus 
dorsi,  the  fibers  of  which  muscle  are  exposed.  The  incision  is  then 
carried  through  the  fibers  of  the  muscle,  when  the  outer  border  of 


406  URINARY  SYSTEM. 

the  erector  spinas  may  be  recognized;  without  opening  its  sheath, 
this  muscle  is  drawn  toward  the  middle  line  with  retractors.  The 
quadratus  lumborum,  covered  by  its  layer  of  lumbar  fascia,  is  then 
exposed  in  the  bottom  of  the  wound.  The  fascia  that  covers  the 
quadratus  lumborum  is  incised  along  the  outer  border  of  the  mus- 
cle, which  is  then  also  drawn  toward  the  spine.  It  is  important 
to  recognize  the  edge  of  this  muscle.  One  should  be  on  the  lookout 
for  the  ilio-hypogastric  nerve,  which  is  derived  from  the  lumbar 
plexus  and  passes  downward  and  outward  across  the  front  of  the 
quadratus  lumborum;  this  nerve  is  usually  seen  after  the  edge  of  the 
quadratus  lumborum  has  been  exposed,  and  should  not  be  cut,  but 
rather  drawn  aside,  out  of  the  way. 

There  remains  now  only  the  deepest  and  last  layer  of  the  lum- 
bar fascia  to  incise,  and  this  should  be  split  the  full  length  of  the 
skin  incision.  In  cutting  through  the  various  layers  of  the  back, 
if  the  patient  rests  upon  the  side,  there  is  a  tendency  to  work  in- 
ward, toward  the  spinal  column,  instead  of  directly  downward, 
through  the  different  layers,  toward  the  kidney,  and  this  should  be 
avoided.  The  incision  should  reach  above  to  the  lower  border  of  the 
last  rib,  but  should  not  be  carried  beyond  this  level  by  carelessly 
passing  the  point  of  the  knife,  within  the  wound,  upward  under- 
neath the  last  rib,  as  the  pleural  cavity  may  be  thus  accidentally 
opened. 

After  having  cut  through  the  deepest  and  last  layer  of  lumbar 
fascia,  the  fatty  capsule,  in  which  the  kidney  is  imbedded,  is  en- 
countered. This  is  separated  from  the  kidney  bluntly,  with  the 
fingers  in  the  wound,  in  order  to  bring  the  kidney  into  the  incision 
for  fixation. 

During  this  step  of  the  operation  one  should  be  careful  not  to 
penetrate  through  the  proper  fibrous  capsule  of  the  kidney,  since, 
if  this  accident  occurs,  one  may  detach  the  true  capsule  of  the  kidney 
from  the  kidney  substance  proper,  instead  of  isolating  the  kidney 
with  its  proper  capsule  intact  from  the  loose  mass  of  fat  in  which 
it  is  lodged.  If  the  kidney  is  displaced,  movable,  it  is  easy  to  reach  it, 
as  it  then  lies  lower  in  the  abdomen.  The  right  kidney  normally 
is  situated  lower  than  the  left.  When  the  kidney  is  sufficiently  free, 
its  outer,  rounded  border  is  brought  up  into  the  wound;  this  is 
greatly  facilitated  by  the  assistant  forcing  it  up  by  pressure  from 
the  front  of  the  abdomen  if  the  patient  lies  upon  the  side.  If  the 
patient  lies  prone,  with  the  Edebohls  cushion  under  the  abdomen, 


OPERATIONS  UPON  THE  KIDNEY.  407 

the  kidney  may  be  brought  into  the  wound  or  entirely  out  upon  the 
back  without  any  counter-pressure  being  made  upon  the  abdomen 
from  in  front. 

The  proper  fibrous  capsule  is  incised  from  above  downward 
along  the  whole  length  of  the  outer,  rounded  border  of  the  kidney, 
and  each  edge  seized  and  separated  from  the  kidney  substance — it 
peels  off  easily — for  a  distance  of  about  one  inch  on  each  side. 

Either  edge  of  the  detached  capsule  is  then  sutured  above  and 
below  with  chromicized  catgut  to  the  corresponding  edge  of  the 
muscles  deep  in  the  wound.  Two  additional  sutures  of  No.  2  chro- 
micized catgut  are  passed  through  the  edges  of  the  muscles  and  car- 
ried deep  through  the  kidney  tissue  proper:  one  of  these  sutures  passes 
through  the  upper  part  of  the  kidney  and  one  through  the  lower  part. 
It  is  probably  more  convenient  to  pass  these  two  deep  kidney  sutures 
first,  leaving  them  untied,  to  be  used  as  tractors  to  hold  the  kidney  in 
position  until  the  stitches  through  the  capsule  have  been  introdiiced 
and  tied.  The  two  deep  stitches  are  then  tied  also,  but  not  too  tight,  as 
they  might  cut  through  the  kidney  tissue.  When  all  the  sutures  have 
been  tied,  it  will  be  seen  that  the  external,  rounded  border  of  the 
kidney,  denuded  of  its  capsule,  is  firmly  fixed  to  the  edges  of  the 
muscles  deep  in  the  wound,  and  in  this  position  it  remains  fixed  as 
the  wound  heals.  Before  tying  the  two  sutures  that  pass  through 
the  kidney  the  edges  of  the  muscles  in  the  incision  may  be  united  by 
several  deep  catgut  stitches. 

The  incision  is  closed  with  interrupted  silk-worm  gut  stitches, 
which  pass  deep  through  both  the  skin  and  muscles,  or  the  muscles 
may  be  united  separately  by  several  deep,  interrupted,  catgut  su- 
tures.    It  is  unnecessary  to  drain  the  wound. 

There  are  usually  no  large  vessels  encountered  during  the  op- 
eration, but  any  spurting  points  may  be  clamped  and  ligated. 

Nephropexy  (Edebohls).  —  An  incision  is  made  which  reaches 
from  the  twelfth  rib  to  the  crest  of  the  ilium  along  the  outer  border 
of  the  erector  spina?;  it  passes  through  the  skin  and  fat  down  to  the 
latissimus  dorsi.  The  fibers  of  the  latissimus  dorsi  are  not  cut,  but 
are  separated  bluntly,  in  the  direction  of  their  course,  with  the 
handle  of  the  knife. 

Corresponding  to  the  outer  edge  of  the  quadratus  lumborum 
muscle,  Avhich  lies  beneath  the  erector  spina?,  the  transversalis  fascia 
is  incised,  thus  entering  the  abdomen  and  exposing  the  mass  of  fat 
(fatty  capsule)  within  which  the  kidney,  enveloped  in  its  proper 


408  UKINARY  SYSTEM. 

fibrous  capsule,  is  imbedded.  One  should  avoid  division  of  the  ilio- 
hypogastric nerve,  a  moderately  large  branch  of  the  lumbar  plexus 
which  passes  obliquely  downward  and  outward  across  the  front  sur- 
face of  the  quadratus  lumborum;  it  should  be  sought  for  at  the 
outer  edge  of  the  quadratus  lumborum,  and  drawn  to  one  side. 

Upon  its  anterior  aspect  and  near  its  outer  edge  the  sheath  of 
the  quadratus  lumborum  is  now  incised  from  the  twelfth  rib  to  the 
crest  of  the  ilium;  this  exposes  a  considerable  area  of  the  raw  ante- 
rior surface  of  the  muscle.  With  the  fingers  in  the  wound  the  fatty 
capsule  is  peeled  off  the  kidney,  and  the  organ,  enveloped  in  its  proper 
fibrous  capsule,  is  delivered  through  the  wound  out  upon  the  back. 
At  times  the  kidney,  still  enveloped  in  its  fatty  capsule,  may  be  de- 
livered through  the  wound,  and  under  these  circumstances  the  fatty 
capsule  may  be  separated  from  the  kidney  almost  as  far  as  the  pelvis, 
and  excised  with  the  scissors. 

The  position  of  the  patient,  prone,  and  with  the  Edebohls 
cushion  underneath  the  abdomen,  makes  the  delivery  of  the  kidney 
comparatively  easy.  If  the  opening  in  the  loin  is  not  sufficiently 
roomy,  it  may  be  enlarged  by  nicking  the  outer  edge  of  the  quad- 
ratus lumborum  below,  near  its  attachment  to  the  ilium. 

A  small  incision  is  made  in  the  capsule  of  the  kidney,  near  the 
middle  of  its  outer,  rounded  border,  and  through  this  opening  a 
director  is  introduced  upon  which  the  capsule  is  divided  along  the 
entire  length  of  the  outer  border  of  the  kidney.  The  capsule  is  then 
peeled  back,  about  half-way  toward  the  pelvis  upon  either  surface, 
thus  laying  bare  about  one-half  of  the  entire  kidney  surface.  The 
detached  part  of  the  capsule  is  not  excised  unless  it  is  quite  redun- 
dant; it  is  simply  folded  back  toward  the  pelvis  of  the  kidney  upon 
the  non-detached  portion. 

Four  fixation  sutures  of  forty-day  chromicized  catgut  are  now 
introduced  through  the  capsule;  these  pass  through  the  capsule 
only,  two  on  each  side,  one  above  and  the  other  below.  Each  of 
these  fixation  sutures  should  take  a  good,  broad  bite,  and  passes 
through  both  the  detached  and  the  non-detached  portions  of  the 
capsule,  parallel  with  and  close  to  the  margin  that  corresponds  to 
the  line  of  its  reflection.  After  these  four  fixation  sutures  have  been 
introduced  the  kidney  is  returned  into  the  abdomen. 

The  ends  (eight  in  number)  of  the  fixation  sutures  are  then,  in 
succession,  one  after  the  other,  threaded  in  a  large  curved  Hagedorn 
needle,  and  carried  through  the  muscles  and  fascia  that  correspond 


OPERATIONS  UPON  THE  KIDNEY. 


409 


to  the  edges  of  the  incision,  from  within  outward.  The  sutures  are 
not  tied  until  later.  Those  sutures  that  pass  through  the  inner 
edge  of  the  incision  penetrate  the  retracted  edge  of  the  incised  sheath 
of  the  quadratus,  the  quadratus  itself,  and  the  erector  spina?  and 
latissimus  dorsi;  the  sutures  that  pass  through  the  outer  edge  of 
the  incision  pierce  the  edge  of  the  transversalis  fascia  and  the  latis- 
simus dorsi  muscle. 

Now,  hefore  tying  the  fixation  sutures  the  edges  of  the  wound 
in  the  back  are  approximated  with  from  four  to  six  chromicized  cat- 


Fig.  176.— Nephropexy  (E  deli  oh  Is).  Kidney  delivered  through  an  incision 
in  the  back.  Proper  fibrous  capsule  reflected  and  two  fixation  sutures  intro- 
duced, one  above  (A,  A')  and  one  below  (B,  B').  These  sutures  pass  through 
the  reflected  and  attached  portions  of  the  capsule  close  to  the  line  of  reflec- 
tion. The  two  sutures  that  secure  the  capsule  upon  the  opposite  side  of 
kidney  are  not  seen. 


gut  sutures;  these  are  interrupted,  and  pass  through  all  the  fascia? 
and  muscles  in  the  edges  of  the  wound.  The  fixation  sutures  are 
then  tied;  they  emerge  upon  the  posterior  surface  of  the  latissimus 
dorsi,  four  upon  each  side  of  the  line  of  division  in  the  muscle.  They 
are  not  tied  across  the  wound,  hut  the  adjoining  ones  of  each  side 
are  tied  to  each  other  upon  the  same  side  of  the  wound. 

The  edges  of  the  skin  are  finally  united  without  drainage  with 
an  intracuticular  suture. 

The  result  of  this  operation  is  to  fix  the  denuded,  raw  surface 


410  URINARY  SYSTEM. 

of  the  kidney,  corresponding  to  the  whole  length  of  its  convex  bor- 
der, and  extending  half  way  to  the  pelvis  upon  either  surface,  to  the 
denuded  anterior  surface  of  the  quadratus  lumborum,  the  upper  ex- 
tremity of  the  kidney  projecting  upward,  beneath  the  last  ribs. 

Nephrotomy. — Cutting  into  the  kidney  for  the  purpose  of  evac- 
uating an  abscess  or  to  explore  the  pelvis  of  the  kidney. 

The  position  of  the  patient  and  the  incision  are  as  described  for 
nephropexy  (page  404).  The  patient  is  placed  either  prone,  with  the 
Edebohls  cushion  underneath  the  abdomen,  or  else  he  rests  upon 
the  well  side.  The  incision  is  carried  down,  step  by  step,  until  the 
last  layer  of  the  lumbar  fascia  has  been  cut  and  the  kidney  is  reached. 
If  operating  for  nephritic  abscess,  we  may  find,  as  soon  as  the  kidney 
is  exposed,  that  the  indications  of  the  abscess  immediately  present 
themselves,  or  it  may  be  necessary  to  search  with  an  exploring  needle. 
When  pus  is  located,  the  cavity  containing  it  is  incised  with  the  point 
of  the  scalpel  and  enlarged  with  dressing  forceps,  which  are  intro- 
duced closed  and  expanded  as  they  are  withdrawn.  At  times  the 
entire  kidney  substance  is  destroyed,  and  simply  a  bag  of  pus  re- 
mains. We  may  or  may  not  find  a  stone.  The  abscess  cavity  is  irri- 
gated and  packed  loosely  with  a  strip  of  iodoform  gauze,  the  end  of 
which  emerges  through  the  lower  part  of  the  wound  in  the  loin. 

In  closing  the  incision  in  the  back  the  stitches  should  be  carried 
deep  in  order  to  include  the  muscles,  together  with  the  skin;  the 
lower  part  is  left  open  for  drainage. 

At  times,  in  order  to  explore  the  pelvis  of  the  kidney  or  to 
drain  it,  it  may  be  necessary  to  bisect  or  split  the  kidney  from  its 
posterior  rounded  border  right  through  into  its  pelvis.  In  doing 
this  care  should  be  exercised  to  divide  the  kidney  midway  between 
its  two  surfaces,  as  this  is  attended  with  less  hemorrhage.  The 
kidney  must  be  brought  up  into  the  wound,  and  may  be  steadied 
there  by  an  assistant  exercising  pressure  from  in  front.  It  is  usually 
sufficient  if  the  incision  in  the  kidney  extends  through  only  a  part 
of  its  length.  In  this  way  a  stone  which  may  escape  the  exploring 
needle  may  be  detected  and  removed,  or,  if  there  is  no  stone  present, 
and  the  symptoms  are  due  to  an  inflammatory  condition  of  the  pelvis, 
this  may  be  drained  through  the  kidney  by  leaving  a  small  tube  or 
a  strip  of  iodoform  gauze,  which  reaches  from  the  pelvis  of  the  kid- 
ney and  emerges  through  the  incision  in  the  loin.  A  resulting  urinary 
fistula  usually  closes  spontaneously,  provided  the  ureter  is  not  ob- 
structed. 


OPERATIONS  UPON  THE  KIDNEY.  411 

The  cut  surfaces  of  the  kidney  may  he  brought  together,  thus 
controlling  hemorrhage  from  the  renal  vessels,  by  passing  several 
deep  sutures  through  the  substance  of  the  kidney.  If  an  individual 
spurting  artery  of  some  size  is  seen,  it  should  he  ligated  separately. 
For  these  sutures  catgut  should  be  used,  and  they  should  be  passed 
in  a  curved  surgeon's  needle. 

The  wound  in  the  loin  is  closed  in  part  by  interrupted,  silk- 
worm gut  sutures,  which  penetrate  deep  through  the  edges  of  the 
muscles,  or  the  edges  of  the  muscles  may  be  united  separately  by 
several  interrupted  catgut  sutures. 

Nephrolithotomy. — Cutting  into  the  kidney  for  stone. 

The  steps  of  this  operation  are  like  those  already  described  in  the 
preceding  operation.  After  the  kidney  has  been  reached  and  brought 
up  into  the  wound  it  may  be  palpated  and  punctured  with  a  fine 
needle,  here  and  there,  in  order  to  locate  the  stone.  It  may  be  found 
in  the  pelvis  of  the  kidney  or  in  the  kidney  tissue  proper.  With  the 
point  of  the  knife,  which  is  passed  along  the  needle  as  a  guide,  an 
incision  is  made  in  the  kidney,  this  opening  being  enlarged  with  an 
artery  forceps,  or  the  pelvis  of  the  kidney  may  be  incised,  and  the  stone 
•extracted. 

If  one  is  unable  to  locate  the  stone  with  the  exploring  needle, 
and  the  symptoms  warrant  it,  the  kidney  may  be  laid  open,  as  in 
the  preceding  operation. 

As  a  rule,  pus  is  associated  with  stone,  and  it  is,  therefore,  usu- 
ally necessary  to  drain  these  cases. 

If  there  is  no  pus,  or  if  small  in  quantity  and  if  the  ureter  is  not 
obstructed,  one  may  omit  drainage  and  allow  the  wound  in  the  kid- 
ney to  close;  if  the  opening  is  large,  a  suture  may  be  introduced. 
If  the  pelvis  of  the  kidney  has  been  opened,  it  may  be  closed  with 
•several  catgut  sutures  introduced  with  a  small,  curved  needle  in  a 
holder.  It  is  well  to  provide  drainage  for  the  incision  in  the  back,  a 
strand  of  gauze  being  packed  into  the  wound  down  to  the  site  of  the 
incision  in  the  kidney  or  pelvis  of  the  kidney. 

Nephrectomy. — Extirpation  of  the  kidney. 

The  position  of  the  patient  is  the  same  as  that  already  described 
for  nephropexy.  The  steps  of  the  operation  are  as  above  indicated 
down  to  the  point  of  exposing  the  kidney.  The  incision  is  the  same 
as  that  described  for  nephropexy  (page  404)  and  should  reach  from 
the  last  rib  to  the  crest  of  the  ilium.  If  necessary,  we  may  obtain 
more  room  by  curving  the  lower  end  of  the  incision  forward,  above  the 


412  URINARY  SYSTEM. 

upper  border  of  the  crest  of  the  ilium.,  or  we  may  make  a  cut  from 
the  upper  end  of  the  lumbar  incision  outward  along  the  lower  border 
of  the  last  rib  (see  Fig.  175). 

The  isolation  of  the  kidney  must  be  thorough,  and  this  is  ac- 
complished with  the  hand  in  the  wound,  working  patiently,  with  the 
fingers,  around  the  kidne}',  care  being  taken  not  to  tug  upon  the 
kidney,  as  one  may  tear  the  vessels  at  the  hilum.  The  suprarenal 
capsule  may  be  left  behind,  although,  if  diseased,  it  may  be  removed 
also.  After  the  kidney  has  been  isolated,  its  outer,  rounded  border 
is  brought  well  into  the  wound,  or,  as  may  be  done  in  nearly  all 
cases,  the  kidney  is  brought  entirely  out  of  the  wound,  so  that  a  liga- 
ture may  be  thrown  around  it  and  worked  down  about  the  structures- 
at  the  hilum — the  vein,  artery,  and  ureter — and  tied,  or  one  may  pass 
the  ligature  with  a  large,  curved,  blunt  ligature  carrier,  the  ligature 
being  carried  about  the  artery  and  vein,  without  including  the  ureter,, 
which  lies  below  the  vessels  and  on  a  plane  posterior  to  them. 

The  ligature  should  be  of  strong  catgut;  after  the  ligature  has 
been  tied  its  ends  should  not  be  cut  short,  as  it  is  desirable  to  use  the 
ligature  as  a  tractor  to  bring  the  stump  of  the  kidney  into  view  for  final 
inspection. 

In  cutting  away  the  kidney  the  division  should  not  pass  through 
the  pedicle,  which  is  made  of  the  vessels,  but,  if  possible,  should  pass 
through  the  kidney  tissue  near  the  hilum,  in  order  to  leave  a  little 
mass  of  kidney  tissue  as  a  cap,  or  knob,  to  prevent  the  slipping  of 
the  ligature. 

The  wound  is  treated  as  in  the  foregoing  operations;  it  is  prob- 
ably better  to  introduce  a  drain,  which  is  left  for  seventy-two  hours. 

When  the  kidney  is  the  seat  of  a  very  large  tumor,  it  may  he- 
difficult  to  remove  it  through  this  posterior  incision. 

We  should  be  positive  that  a  second  kidney,  which  is  capable 
of  carrying  on  the  work,  is  present,  and,  if  necessary  at  the  time  of 
the  operation,  an  incision  may  be  made  down  upon  the  other  kidney 
in  order  to  satisfy  ourselves  of  its  presence. 

Decortication  of  the  Kidney  (Edebohls).  —  This  operation  was- 
first  suggested  for  the  cure  of  chronic  Bright's  disease,  by  Edebohls. 
The  operation  is  recent,  and  its  real  value  still  sub  judice.  The  bene- 
ficial effect  of  the  operation  is,  no  doubt,  due  to  the  increased  supply 
of  blood  that  is  brought  to  the  kidney  through  the  new  vascular  con- 
nections that  are  formed  between  it  and  the  adjacent  parts. 

Edebohls  says  that  one  may  use  the  anresthetic,  ether  or  chloro- 


SURGICAL  ANATOMY  OF  THE  BLADDER.  413 

form,  with  which  he  is  most  familiar.  Mixed  nitrous  oxide  and  oxygen 
is  very  well  adapted  to  certain  cases.  It  would  seem  that  chloroform 
would  be  more  satisfactory  in  most  cases.  Spinal  analgesia  would,  no 
doubt,  be  appropriate  in  some  of  these  cases,  where  the  patient's  con- 
dition counter-indicates  the  use  of  a  general  anaesthetic. 

The  patient  lies  prone  upon  the  table,  with  the  Edebohls  cushion 
under  the  abdomen.  The  incision,  the  same  as  that  described  for 
nephropexy  (page  407),  corresponds  to  the  edge  of  the  erector  spina?, 
and  penetrates  the  transversalis  fascia  along  the  outer  edge  of  the 
quadratus  lumborum.  The  kidney  is  recognized  in  the  mass  of  fat, 
fatty  capsule,  that  incloses  it. 

With  the  fingers  in  the  wound  the  fatty  capsule  is  separated 
bluntly  from  the  surface  of  the  kidney  as  far  as  the  pelvis.  The  kid- 
ney, inclosed  within  its  unbroken  fibrous  capsule,  is  then  drawn  into 
the  wound,  or,  if  possible,  lifted  out  of  the  wound  upon  the  back. 

Corresponding  to  the  middle  of  the  outer,  rounded  border  of  the 
kidney,  the  capsule  proper  is  incised,  and  divided  upon  a  director 
along  the  entire  length  of  the  outer,  rounded  border  of  the  organ,  and 
around  its  extremities,  above  and  below.  Each  half  of  the  capsule  is 
then  stripped  away  from  the  surface  of  the  kidney  toward  the  pelvis, 
taking  care  not  to  break  or  tear  the  kidney  substance  proper,  which 
may  be  friable  and  firmly  adherent  to  the  capsule. 

The  stripped  off  capsule  is  finally  cut  away  near  the  pelvis  of  the 
kidney,  and  removed.  If  the  kidney  cannot  be  brought  out  through 
the  incision  in  the  back,  the  capsule  must  be  peeled  off  the  kidney, 
with  the  fingers  in  the  wound,  and  excised,  as  far  as  possible. 

Any  portion  of  the  capsule  that  still  remains  may  be  rolled  back 
toward  the  pelvis  of  the  kidney,  where  it  remains  coiled  up,  upon 
itself. 

The  kidney  is  finally  replaced  in  the  abdomen,  and  the  incision 
closed  without  drainage.  At  the  time  of  operation  it  may  appear  that 
but  one  kidney  is  the  seat  of  chronic  Bright' s  disease,  but  it  is  prob- 
ably wise  in  all  cases  to  decapsulate  both  kidneys  at  the  same  sitting. 

THE  BLADDER. 

Surgical  Anatomy  of  the  Bladder. — The  bladder  is  a  hollow  mus- 
cular organ  whose  function  is  to  receive  and  hold  the  urine  during 
the  intervals  of  micturition.  It  has  a  capacity  ordinarily  of  about 
sixteen  ounces. 


414  URINARY  SYSTEM. 

In  the  infant  the  bladder  is  rather  conical,  and  projects  into  the 
abdomen  above  the  level  of  the  symphysis. 

In  the  adult  the  bladder,  when  empty,  lies  deep  within  the  pelvis 
behind  the  symphysis,  its  cavity  obliterated  and  its  walls  collapsed 
and  in  contact  with  each  other.  When  distended  moderately,  it 
reaches  as  high  as  the  symphysis,  farther  distension  causing  it  to  rise 
up,  out  of  the  pelvis,  into  the  abdominal  cavity  a  varying  distance 
toward  the  umbilicus.  When  it  is  distended  with  about  a  pint  of 
fluid,  the  bladder  is  pear-shaped,  and  reaches  for  a  distance  of  about 
four  inches  above  the  symphysis. 

The  body  of  the  bladder  is  free,  and,  when  the  organ  is  distended, 
rises  out  of  the  pelvis  into  the  abdomen,  toward  the  umbilicus. 

The  base  of  the  bladder  in  the  male  is  in  close  relation  with  the 
anterior  surface  of  the  second  part  of  the  rectum,  and  upon  its  inner 
aspect,  on  either  side,  shows  the  openings  of  the  ureters. 

The  neck  of  the  bladder  is  continuous  with  the  commencement 
of  the  urethra,  and  in  the  male  is  surrounded  by  the  prostate,  like  a 
collar. 

Eelations  of  the  Bladdek.  In  the  Male  the  bladder  is  in  rela- 
tion, behind,  with  the  rectum,  the  base  of  the  bladder  lying  directly 
in  front  of  the  second  portion  of  this  part  of  the  bowel,  the  two  being 
joined  together  more  or  less  intimately  by  connective  tissue. 

The  seminal  vesicles  and  vas  deferens  are  located  on  either  side 
of  the  middle  line,  in  the  space  between  the  contiguous  walls  of  the 
rectum  and  the  bladder;  they  converge  anteriorly  toward  the  pros- 
tate, which  surrounds  the  neck  of  the  bladder,  and  which  is  readily 
felt  through  the  rectum. 

In  the  Female  the  uterus  and  vagina  are  located  behind  the 
bladder. 

In  both  sexes  the  bladder  lies  immediately  behind  the  symphysis 
pubis,  from  which  it  is  separated  by  a  space,  which  is  filled  with  loose 
connective  tissue  more  or  less  firmly  connected  with  the  anterior  wall 
of  the  bladder,  and  which  is  called  the  space  of  Eetzius.  When  the 
bladder  is  distended,  it  reaches  above  the  symphysis,  and  is  then  in 
relation,  in  front,  with  the  anterior  abdominal  wall. 

Passing  from  the  summit  of  the  bladder  to  the  umbilicus  is  the 
urachus,  which  occasionally  remains  patent  after  birth. 

The  peritoneum  covers  the  sides,  part  of  the  posterior  surface, 
and  the  summit  of  the  bladder,  but  does  not  cover  its  anterior  surface, 
being  reflected  from  the  summit  of  the  bladder  over  on  to  the  poste- 


OPERATIONS  UPON  THE  BLADDER. 


415 


rior  surface  of  the  anterior  abdominal  wall.  When  the  bladder  is 
well  distended,  it  rises  upward  into  the  abdomen;  its  summit,  as  it 
approaches  the  umbilicus,  carries  the  peritoneum  with  it,  and  its  ante- 
rior surface,  which  is  devoid  of  peritoneum,  then  comes  into  relation 
with  the  abdominal  wall;  so  that  under  these  circumstances  the  blad- 
der may  be  entered  through  an  incision  in  the  anterior  abdominal 
wall,  low  down,  close  to  the  symphysis,  without  molesting  the  peri- 
toneum or  entering  the  peritoneal  cavity. 


Fig.  177. — An  Anteroposterior  Section  Showing  Relations  of  the  Perito- 
neum to  the  Bladder,  etc.  Bladder  moderately  distended.  P,  prostate  gland 
surrounding  commencement  of  the  urethra  (neck  of  the  bladder) ;  PP,  ante- 
rior fold  of  peritoneum  reflected  from  the  posterior  aspect  of  the  anterior 
abdominal  wall  over  on  to  the  fundus  of  the  bladder;  SP,  symphysis  pubis; 
VS,  vesiculse  seminales. 

The  higher  the  bladder  ascends  into  the  abdomen,  the  larger  the 
area  of  its  anterior,  non-peritoneal  surface  which  is  presented  for 
operation. 


OPERATIONS  UPON  THE  BLADDER. 

Suprapubic  Cystotomy.  —  The  patient  is  placed  in  the  usual 
position  upon  the  back  and  fully  anaesthetized,  so  as  to  relax  the  ab- 
dominal muscles.    If  one  is  unable  to  distend  the  bladder,  owing  to 


416  URINARY  SYSTEM. 

the  existence  of  an  impassable  stricture  of  the  urethra,  etc.,  much 
advantage  is  gained  by  placing  the  patient  in  the  Trendelenburg 
position. 

A  soft  rubber  catheter  is  introduced  into  the  bladder,  and, 
through  this,  the  bladder  is  washed  out  with  boric-acid  solution,  10  to 
12  ounces  being  allowed  to  remain;  the  catheter  is  then  withdrawn, 
and  a  band  tied  about  the  penis  to  prevent  the  escape  of  the  fluid. 
The  fluid  which  is  thrown  into  the  bladder  causes  it  to  ascend  into 
the  abdomen,  carrying  the  peritoneum  with  it;  so  that  its  anterior 
surface,  uncovered  by  peritoneum,  is  exposed  for  several  inches  for 
operation.  It  is  well  not  to  introduce  more  than  10  to  12  ounces,  as 
oftentimes  the  capacity  of  the  bladder  is  diminished,  and  a  quantity 
above  12  ounces  might  do  harm. 

In  order  to  throw  the  distended  bladder  farther  forward  toward 
the  anterior  abdominal  wall,  a  bag  may  be  introduced  into  the  rectum 
and  distended  with  about  6  ounces  of  water.  Most  operators  dispense 
with  the  rectal  bag  as  unnecessary.  The  incision,  which  is  placed  in 
the  middle  line,  linea  alba,  commences  below,  at  the  symphysis  pubis, 
and  reaches  upward,  toward  the  umbilicus,  for  a  distance  of  about 
three  inches,  and  extends  through  the  skin  and  fat  down  to  the  deep 
fascia.     Bleeding  vessels  in  the  skin  are  clamped. 

The  incision  is  carried  down  through  the  linea  alba,  between  the 
edges  of  the  recti  and  pyramidales,  until  the  layer  of  connective  tissue, 
which  is  located  in  front  of  the  bladder,  dipping  down  between  it  and 
the  symphysis  pubis,  is  reached. 

The  edges  of  the  wound  are  then  drawn  apart  with  retractors, 
and  this  layer  of  connective  tissue,  which  covers  the  anterior  wall  of 
the  bladder,  is  scraped  upward,  toward  the  umbilicus,  with  the  finger- 
nail; so  that,  in  case  the  fold  of  peritoneum  reaches  abnormally  low, 
or  the  bladder  has  not  been  sufficiently  distended,  we  may  thus  still 
separate  it  and  carry  it  upward  toward  the  umbilicus.  The  muscular 
wall  of  the  bladder  is  then  easily  recognized,  especially  if  the  organ  is 
distended.  A  plexus  of  veins,  more  or  less  visible,  which  ascends 
upon  the  anterior  wall  of  the  bladder  from  below,  may  help  to  identify 
it. 

With  a  curved  surgeon's  needle  two  rather  stout  silk  stitches  are 
introduced,  one  on  either  side  of  the  middle  line,  through  the  whole 
thickness  of  the  bladder  wall,  and  these  are  used  as  tractors  to  steady 
the  bladder  while  it  is  being  incised. 

In  cutting  into  the  bladder  the  point  of  the  knife  is  introduced 


OPERATIONS  UPON  THE  BLADDER.  417 

between  the  two  silk  tractor  stitches  about  one  inch  above  the  sym- 
physis, and  the  bladder  incised  in  a  direction  downward,  toward  the 
symphysis.  When  the  bladder  is  opened  the  fluid  contained  within 
it  escapes  in  part.  The  incision  should  be  large  enough  to  permit 
the  introduction  of  one  or  two  fingers  for  the  purpose  of  exploration, 
etc. 

The  incision  in  the  bladder  may  be  enlarged  sufficiently  to  allow 
necessary  manipulation;  caution  should  be  exercised  in  extending  the 
opening  in  the  bladder,  for  any  considerable  distance,  in  an  upward 
direction,  toward  the  umbilicus  (fold  of  peritoneum). 

If  a  stone  is  present,  it  may  be  removed  with  the  forceps,  guided 
by  the  finger;  if  the  stone  is  very  large,  it  may  first  be  crushed.  One 
should  search  the  bladder  carefully  for  stones  which  have  become 
almost  completely  encysted  in  pockets  in  the  bladder  wall.  If  the 
operation  is  done  for  ulcer  of  the  bladder,  the  diseased  area  may  be 
scraped  or  cauterized,  etc.  With  the  patient  in  the  Trendelenburg 
position  and  the  edges  of  the  wound  drawn  asunder  with  broad  re- 
tractors, the  interior  of  the  bladder  may  be  illuminated  and  made 
visible;  an  hypertrophied  prostate  may  be  enucleated  through  the 
suprapubic  opening. 

After  the  work  within  the  bladder  has  been  completed,  the  open- 
ing may  be  closed  with  a  line  of  sutures.  They  should  bring  the  edges 
of  the  opening  in  the  bladder  into  accurate  apposition,  and  should 
pass  through  all  the  layers  of  the  wall  of  the  bladder  down  to,  but 
not  including,  the  mucous  membrane.  None  of  the  sutures  should 
pass  through  the  whole  thickness  of  the  wall  of  the  bladder.  Fine 
silk  or  catgut  may  be  used. 

If  the  opening  in  the  bladder  wall  is  closed,  the  incision  in  the 
wall  of  the  abdomen  should  be  left  open,  at  least  in  part,  and  packed, 
in  order  to  provide  drainage;  it  will  also  be  necessary  to  leave  a  cath- 
eter in  the  urethra  for  several  days.  In  most  cases  it  is  probably  wise 
to  leave  the  incision  in  the  bladder  unclosed,  stitching  the  margins  of 
the  opening  in  the  bladder  to  the  edges  of  the  muscles  in  the  abdom- 
inal wound  with  two  or  three  interrupted  silk  sutures  on  either  side, 
their  ends  being  left  long  to  facilitate  their  removal  later.  There 
are  introduced  through  the  suprapubic  opening  into  the  bladder  two 
drainage  tubes.  One  of  the  tubes  is  long,  and  reaches  from  the  bottom 
of  the  bladder  over  the  side  of  the  bed  into  a  bottle  partly  filled  with 
an  antiseptic  solution  and  suspended  from  the  side  of  the  bed.  The 
second  tube,  which  is  short,  is  for  the  purpose  of  assisting  siphonage 


418  URINARY  SYSTEM. 

of  the  bladder  and  to  facilitate  irrigation.  These  tubes  are  fixed  in 
the  bladder  by  passing  the  silk  tractor  stitches  (which  were  introduced 
in  the  early  stage  of  the  operation)  through  the  tubes.  The  wound 
is  packed  loosely  about  the  tubes  with  iodoform  gauze. 

The  fistula  that  remains  after  the  tubes  are  removed  rapidly 
diminishes  in  size,  and  finally  closes  spontaneously,  provided  the  ure- 
thral canal  is  unobstructed.  In  many  cases  it  will  suffice  to  fix  the 
tubes  in  the  bladder  with  the  silk  tractor  sutures,  omitting  the  sutur- 
ing of  the  edges  of  the  opening  in  the  bladder  to  the  abdominal  inci- 
sion. 

Puncture  of  the  Bladder  may  be  made  in  the  middle  line  just 
above, the  symphysis,  or  through  the  rectum.  It  is  done  for  the  pur- 
pose of  drawing  off  the  urine  when  the  patient  is  unable  to  empty  the 
bladder  through  the  urethra.  One  should  first  satisfy  himself  by  per- 
cussion, etc.,  that  the  bladder  is  actually  distended. 

A  medium-sized  curved  trochar  is  introduced  above  the  symphy- 
sis; it  should  be  thrust  through  the  anterior  abdominal  wall  in  the 
middle  line  just  above  the  symphysis,  and  in  a  direction  backward  and 
downward,  toward  the  sacrum,  for  a  distance  of  two  or  three  inches. 

If  introduced  through  the  rectum,  the  trochar  should  be  guided 
upon  the  finger  into  the  rectum  beyond  the  base  of  the  prostate,  at 
which  point  it  is  thrust  into  the  bladder  in  a  direction  upward  and 
forward,  toward  the  symphysis.  The  suprapubic  route  is  probably 
preferable. 

THE  PENIS. 

Surgical  Anatomy  of  the  Penis. — The  penis  when  erect  is  pris- 
moid  in  shape.  It  is  composed  of  the  corpora  cavernosa  and  the 
corpus  spongiosum. 

The  corpora  cavernosa  are  two  cylinders  of  erectile  tissue  which 
run  parallel  with  each  other  and  occupy  the  upper  part  of  the  organ. 
They  consist  of  a  mesh-work  of  vascular  spaces,  which  may  readily 
become  distended  with  blood,  thus  bringing  the  penis  into  a  con- 
dition of  erection.  They  are  each  provided  with  a  strong,  fibrous 
envelope,  the  tunica  albuginea,  and  behind  diverge,  to  be  attached 
to  the  rami  of  the  pubes. 

The  corpus  spongiosum  is  situated  below  the  corpora  cavernosa, 
and  contains  the  urethral  canal,  which  is  also  surrounded  by  cavern- 
ous, or  erectile,  tissue. 

The  end  of  the  penis  is  enlarged,  rather  bulbous,  and  is  known 


OPERATIONS  UPON  THE  PENIS.  419 

as  the  glans;  this  is  really  the  enlarged  extremity  of  the  corpus 
spongiosum.  Behind,  in  the  perineum,  the  corpus  spongiosum  is 
enlarged  and  forms  the  hulh.  The  penis  at  its  root  is  firmly  con- 
nected to  the  symphysis  hy  a  fibrous  band,  the  suspensory  ligament. 

The  three  cylinders  which  together  form  the  penis  are  bound 
together  by  a  fibrous  sheath,  and  covered  with  a  soft,  loose,  movable 
envelope  of  skin,  which,  at  the  extremity,  is  reflected  over  the  glans 
for  a  greater  or  less  distance,  forming  the  prepuce.  The  constriction 
behind  the  glans  is  called  the  corona. 

Passing  forward  along  the  dorsal  surface  of  the  penis,  in  the 
groove  between  the  corpora  cavernosa,  are  two  arteries,  one  on  each 
side,  the  dorsal  arteries  of  the  penis,  branches  of  the  internal  pudic, 
and  lying  between  the  two  arteries  is  the  single  dorsal  vein. 

OPERATIONS  UPON  THE  PENIS. 

Forcible  Dilatation  of  the  Prepuce  for  Phimosis. — This  may  be 
practiced  in  many  cases,  especially  in  newborn  and  young  children, 
instead  of  a  dorsal  section  or  circumcision.  An  anaesthetic  is  unnec- 
essary. The  skin  of  the  prepuce  is  seized  and  peeled  forcibly  back- 
ward over  the  glans  as  far  as  the  corona.  This  is  readily  done  in 
most  cases,  even  when  the  orifice  of  the  prepuce  is  quite  narrow. 
The  margin  of  the  prepuce  stretches  and  suffers  slight  tears  here 
and  there  about  its  circumference;  it  should  be  drawn  back  and 
forth  several  times,  and  again  repeated  daily  for  several  days.  When 
the  prepuce  is  drawn  back,  any  hardened  smegma  that  has  accumu- 
lated should  be  removed,  and  the  glans  washed  and  smeared  with 
oil  or  vaselin;  the  skin  is  then  again  drawn  forward  over  the  glans, 
since  the  constriction  of  the  narrow  prepuce  might  cause  some  incon- 
venience if  allowed  to  remain  back  behind  the  glans.  After  the  fore- 
skin has  been  drawn  back  and  forth  over  the  glans  a  dilator  may  be 
introduced  into  its  orifice,  and  it  may  then  be  forcibly  and  thoroughly 
dilated.    In  most  cases  this  is  unnecessary. 

Dorsal  Section. — This  operation  is  done  for  phimosis  in  the 
young,  when  one  is  unable  to  retract  the  skin  and  when  it  is  not 
desirable  to  clo  a  complete  circumcision,  and  in  adults  in  all  cases 
where  it  is  necessary  to  expose  the  glans  for  treatment. 

The  skin  of  the  penis  is  rolled  slightly  back  toward  the  root  of 
the  organ  with  the  finger  and  thumb,  and  one  blade  of  a  blunt- 
pointed  scissors  introduced  beneath  the  prepuce,  between  it  and  the 


420 


URINARY  SYSTEM. 


glans,  as  far  back  as  the  corona,  and  the  foreskin  then  divided  along 
the  middle  line,  steadying  it  so  that  it  will  not  roll  or  slip.  The 
scissors  should  be  sharp,  especially  toward  the  ends. 

The  prepuce  should  not  be  divided  for  its  whole  length,  but  only 
to  within  a  short  distance  of  the  corona. 

One  should  be  careful  not  to  introduce  the  blade  of  the  scissors 
into  the  urethral  canal  instead  of  between  the  glans  and  prepuce; 
this. might  happen  if  the  prepuce  were  intimately  adherent  to  the 
surface  of  the  glans,  as  is  sometimes  the  case. 

Instead  of  using  the  scissors  the  section  may  be  made  with  a 
sharp-pointed,   curved  bistoury,   guided   upon   a   grooved   director, 


Fig.  178. — Dorsal  Section  (Roser).  Prepuce  has  been  divided  upon  the 
dorsal  aspect.  M,  edge  of  incised  mucous  membrane;  8,  edge  of  skin.  Dotted 
lines  indicate  little  triangular  flap  (F)  of  mucous  membrane  that  is  cut  from 
the  mucous  to  the  skin  edge  of  the  divided  prepuce.  The  flap  is  turned  back 
and  sutured  into  the  angle  of  the  wound;  the  edge  of  mucous  membrane  and 
skin  may  also  be  joined  on  each  side  with  one  or  two  stitches. 


which  is  introduced  underneath  the  prepuce,  between  it  and  the 
glans.    As  a  rule,  there  is  but  little  hemorrhage. 

If  the  parts  are  not  infected,  one  or  two  catgut  stitches  may  be 
introduced  on  either  side.  Usually  no  suture  is  necessary  in  the 
child. 

Eosee's  Method  of  Doesal  Section. — After  the  dorsal  section 
has  been  made,  the  mucous  membrane  not  being  cut  as  far  back  as 
the  skin,  an  oblique  incision  is  made,  on  either  side,  from  the  corner 
of  the  mucous  membrane  backward  and  outward  as  far  as  the  edge  of 
the  skin.  The  little  triangular  mucous  membrane  flap  which  is  thus 
formed  is  then  turned  up  into  the  angle  in  the  skin,  to  insure  rapid 


OPERATIONS  UPON  THE  PENIS.  421 

healing  in  the  corner  of  the  incision;  it  may  be  held  in  place  with  one 
stitch  in  the*  angle  of  the  incision.  One  or  two  stitches  may  also  be 
introduced  on  either  side  of  the  incision  proper. 

Circumcision. — In  children  an  aneesthetic  is  necessary;  in  adults 
the  operation  may  be  done  under  the  influence  of  cocain,  which  is 
injected  into  the  prepuce  after  a  strip  of  gauze  has  been  tied  fairly 
tight  about  the  body  of  the  penis  near  its  root  to  prevent  diffusion 
of  the  cocain.  One  should  avoid  cutting  the  skin  too  short.  After 
the  parts  have  healed  there  should  be  a  little  redundancy  of  the  skin 
marking  the  previous  reflection  of  the  prepuce,  and  this  is  best  ac- 
complished by  drawing  the  skin  a  little  backward,  toward  the  root 
of  the  penis,  before  applying  the  constricting  band.     The  first  step 


Fig.  179. — Circumcision.  Dorsal  section  has  been  made.  The  corners  of 
the  divided  prepuce  are  grasped  with  artery  forceps  preparatory  to  trimming 
it  away  with  the  scissors. 

in  the  operation  is  the  dorsal  section  of  the  prepuce.  One  blade  of 
a  scissors  is  introduced  underneath  the  prepuce  to  a  point  just  in 
front  of  the  corona,  and  the  prepuce  then  divided  to  within  a  short 
distance  of  the  corona.  Either  corner  of  the  divided  prepuce  is  seized 
with  an  artery  clamp  close  to  the  edge  of  the  incision,  and  with  a 
straight,  blunt-pointed  scissors  the  redundant  portion  of  the  prepuce 
is  trimmed  off,  first  around  one  side  and  then  around  the  other  as 
far  as  the  attachment  of  the  frsenum,  and  finally  cut  through  in  this 
situation,  just  in  front  of  the  frsenum  and  without  dividing  the  fras- 
num. 

The  entire  length  of  the  prepuce  should  not  be  amputated; 
about  one-fourth  its  length  should  remain. 


422  URINARY  SYSTEM. 

As  a  rule,  the  bleeding  stops  when  the  ligature  around  the  penis 
is  removed  and  after  a  few  minutes'  compression.  Bleeding  arterial 
points,  however,  should  he  seized  with  a  clamp  and  twisted.  All 
bleeding  should  be  checked  before  suturing,  if  necessary  applying 
fine  catgut  ligatures. 

The  edges  of  the  skin  and  mucous  membrane  are  united  with 
interrupted  catgut  sutures,  the  first  being  applied  in  the  middle  line 
above,  the  next  in  the  middle  line  below,  then  one  on  each  side,  and 
finally  in  the  intervals  between  these,  making  eight  sutures  in  all. 
In  the  child,  as  a  rule,  the  four  sutures  are  sufficient. 
Circumcision  with  the  Clamp. — After  the  parts  have  been  anaes- 
thetized, etc.,  the  edge  of  the  prepuce  is  seized  above  in  the  middle 
line  and  below  in  the  middle  line  with  artery  forceps,  and  drawn 
forcibly  forward  over  the  glans.  That  part  of  the  prepuce  which 
is  thus  pulled  beyond  the  glans  is  grasped  between  the  blades  of  a 
long,  straight  clamp,  which  is  applied  obliquely  from  above  downward 
and  forward;  the  clamp  should  seize  the  foreskin  firmly,  and  care 
should  be  observed  that  the  glans  is  not  included;  this  accident,  how- 
ever, is  not  likely  to  occur. 

That  part  of  the  prepuce  which  protrudes  beyond  the  blades  of 
the  clamp  is  trimmed  off  with  a  sharp  knife  or  with  the  scissors  plane 
with  the  surface  of  the  clamp,  and  the  clamp  then  removed.  The 
hemorrhage  is  controlled  and  the  sutures  applied  as  above. 

Amputation  of  the  Penis. — This  operation  is  done  for  malignant 
disease.  A  sound  is  passed  into  the  urethra,  and,  supported  upon 
this,  the  penis  is  lifted  away  from  the  body.  An  elastic  ligature  is 
placed  about  the  organ  close  to  its  root. 

A  circular  incision  is  made  through  the  integument  and  a  flap 
reflected  sufficiently  long  to  cover  over  the  stump  of  the  penis;  it 
should  be  equal  in  length  to  half  the  diameter  of  the  penis  plus  one- 
third  for  shrinkage.  After  the  flap  has  been  turned  back  like  a  cuff 
the  portion  of  the  penis  that  is  to  be  amputated  is  cut  away.  The 
urethral  portion  of  the  penis  should  be  cut  about  one-fourth  inch 
longer  than  the  part  that  corresponds  to  the  corpora  cavernosa. 

The  blade  of  the  scalpel  is  thrust  flatwise  through  the  penis 
between  the  urethral  portion,  which  may  be  recognized  by  the  sound 
within,  and  the  corpora  cavernosa,  and  carried  a  good  one-fourth 
inch  forward  toward  the  glans,  when  the  urethral  portion  is  cut 
through  with  a  circular  sweep  of  the  knife  down  upon  the  sound 
contained  within.     The  corpora  cavernosa  are  then  divided  upon  a 


OPERATIONS  UPON  THE  PENIS. 


423 


plane  farther  back,  corresponding  to  the  base  of  the  skin  flap,  so  that 
the  urethral'  portion  will  project  about  one-fourth  inch  beyond  the 
cut  surface  of  the  corpora  cavernosa. 

The  tourniquet  is  now  removed  from  the  root  of  the  penis.  The 
dorsal  arteries  bleed,  and  require  to  be  clamped  and  ligated.  The 
arteries  of  the  corpora  cavernosa  usually  require  no  ligatures;   if  they 


Pig.  180.— Amputation  of  the  Penis.     CC,  corpora  cavernosa;    F,  skin  flap 
turned   back;     U,    urethral   portion   cut   long. 

spurt,  they  may  be  clamped  or  touched  with  the  Paquelin.  A  few 
minutes'  compression  usually  suffices  to  check  bleeding  from  any  re- 
maining sources. 

The  edges  of  the  urethra  are  seized  with  two  artery  clamps,  and 
the  urethra  then  split  upon  its  under  aspect  for  a  distance  of  about 
one-fourth  inch.     The  skin  flaps  are  turned  over  the  end  of  the 


Fig.  181.— Amputation  of  the  Penis.  Edges  of  skin  flap  united  to  each 
other  over  the  ends  of  the  corpora  cavernosa  and  to  the  edges  of  the  split 
urethral  portion. 

stump,  and  are  united  from  before  backward  with  several  inter- 
rupted sutures,  and  the  edges  of  the  split  urethral  orifice  are  sewed 
to  the  adjoining  edges  of  the  skin  flaps. 

The  object  of  cutting  the  urethra  long  and  splitting  it  is  to 
provide  a  larger  orifice  to  allow  for  subsequent  contraction. 

A  soft  rubber  catheter  is  introduced  into  the  bladder  and  al- 


42  -±  URINARY  SYSTEM. 

lowed  to  remain  for  several  days,  its  end  emerging  through  the 
dressings.  It  may  be  fixed  with  a  silk  stitch  to  the  edge  of  the  urethral 
orifice. 

THE  PERINEUM  AND  ISCHIO=RECTAL  REGION. 

The  Floor  of  the  Pelvis  from  "Without  Inward.  —  This  space  is 
lozenge-shaped;  its  front  portion  is  limited  on  either  side  by  the 
rami  of  the  pubes  and  ischium;  its  posterior  part  is  limited  on  either 
side  by  the  edges  of  the  great  sacro-sciatic  ligaments.  The  anterior 
angle  corresponds  to  the  symphysis  pubis,  the  posterior  angle  to  the 
tip  of  the  coccyx,  and  on  either  side  the  tuber  ischii  may  be  felt. 
There  is  a  more  or  less  complete  fibrous  raphe  running  from  before 
backward  in  the  middle  line,  and  also  one  from  side  to  side  where 
all  the  layers  of  the  perineal  fascia  are  blended  together.  Where  these 
lines  intersect  there  is  a  point  where  muscles  are  attached  and  take 
origin  and  where  all  the  fasciae  are  joined.  This  is  known  as  the  cen- 
tral tendinous  point  of  the  perineum.  The  space  in  front  of  the  trans- 
verse raphe  is  the  perineum  proper;  the  space  behind  it  is  occupied 
by  the  anus  and  upon  either  side  by  the  ischio-rectal  fossa,  and  is 
known  as  the  ischio-rectal  region. 

The  Superficial  Layer  of  the  Superficial  Perineal 
Fascia. — Beneath  the  skin  there  is  a  layer  of  loose  fascia  which  is 
continuous  with  the  superficial  fascia  of  the  thighs  and  buttocks. 
This  is  the  superficial  layer  of  the  superficial  fascia  of  the  perineum 
and  ischio-rectal  regions;  it  corresponds  to  the  subcutaneous  fat,  and 
is  continuous  in  front  with  the  dartos  layer  of  the  scrotum,  and  be- 
hind, upon  either  side  of  the  anus,  it  is  packed  into  the  ischio-rectal 
fossa  as  a  pyramidal  plug  of  fat  and  loose  connective  tissue. 

The  Deep  Layer  of  Superficial  Perineal  Fascia. — If  we 
remove  this  superficial  layer  of  fascia  and  fat,  including  the  mass 
from  the  ischio-rectal  fossa,  we  come  down  upon  a  second  layer  of 
fascia,  the  deep  layer  of  the  superficial  fascia  of  the  perineum.  Cor- 
responding to  the  perineal  region  proper,  the  fascia  is  attached  upon 
each  side  to  the  edge  of  the  pubic  arch  and  behind  to  the  transverse 
raphe;  in  front  it  is  continuous  with  the  dartos  of  the  scrotum;  be- 
hind, in  the  ischio-rectal  region,  it  is  continuous  with  the  anal  fascia, 
which  covers  the  perineal  surface  of  the  levator  ani  muscles. 

Anteriorly  this  fascia  is  dense,  and  serves  to  close  in  the  struct- 
ures proper  to  the  perineum.  If  fluid  is  injected  underneath  this 
layer  of  fascia,  it  will  not  spread  backward  beyond  the  transverse 


PERINEUM  AND  ISCHIORECTAL  REGION.  425 

raphe,  because  this  layer  of  fascia  is  attached  along  this  raphe  with 
the  next  underlying  fascial  layer;  it  will  not  escape  laterally,  owing 
to  the  attachment  of  the  fascia  to  the  margins  of  the  bony  pelvic 
arch;  but  anteriorly  it  will  escape,  passing  into  the  dartos  tissue  of 
the  scrotum  and  thence  upward  upon  the  front  of  the  pubes. 

The  Ischio-rectal  Region. — This  is  the  region  which  lies  behind 
the  transverse  raphe — that  part  which  corresponds  to  the  anus  and 
the  ischio-rectal  fossa. 

In  the  middle  is  the  anus,  surrounded  by  its  external  sphincter 
muscle.  This  muscle  arises  from  the  tip  of  the  coccyx  behind,  and, 
passing  forward,  is  attached,  in  front  of  the  anus,  to  the  middle 
tendinous  point  of  the  perineum,  which  corresponds  to  the  junction 
of  the  sphincter  from  behind,  the  transversus  perinei  from  each  side, 
and  the  bulbo-cavernosus  from  in  front. 

On  either  side  of  the  anus  there  is  a  pyramidal  space,  the  ischio- 
rectal fossa;  this  space  is  occupied  by  a  mass  of  fat  and  loose  con- 
nective tissue,  the  base  of  which  corresponds  to  the  superficial  layer 
of  superficial  perineal  fascia,  and  reaches  from  the  tuberosity  of  the 
ischium  to  the  anus.  This  space  is  about  two  inches  deep.  Its  outer 
wall  is  formed  by  the  tuber  ischii  and  the  obturator  internus  muscle, 
which  muscle  is  covered  over  by  a  layer  of  fascia,  the  obturator  fascia. 
Passing  forward  upon  this  outer  wall  of  the  ischio-rectal  fossa,  be- 
neath the  obturator  fascia  and  about  one  and  one-half  inches  above 
the  tuberosity  of  the  ischium,  are  the  internal  pudic  vessels  and 
nerve. 

The  inner  wall  of  the  ischio-rectal  space  is  formed  by  the  levator 
ani  (to  be  described  later).  The  superficial  surface  of  this  muscle, 
which  looks  into  the  ischio-rectal  space,  is  covered  by  the  anal  fascia, 
which  is  derived  from  the  obturator  fascia  along  the  line  of  the 
origin  of  the  levator  ani  from  the  side  of  the  pelvis.  This  anal 
fascia  is  attached  in  front  to  the  transverse  fibrous  raphe  and  is 
continuous  there  with  the  deep  layer  of  the  superficial  perineal  fascia. 

The  ischio-rectal  space  is  thus  walled  off  from  the  perineal  space 
proper  and  from  the  rectum.  It  is  the  seat  of  the  so-called  ischio- 
rectal abscess,  and  when  this  breaks  through  into  the  rectum  it  forms 
the  fistula  in  ano. 

Some  small  vessels  and  nerve  branches  cross  this  space  trans- 
versely just  beneath  the  skin,  passing  from  the  tuberosity  of  the 
ischium  toward  the  anus,  and  these  are  cut  when  incisions  are  made 
into  the  space. 


426 


URINARY  SYSTEM. 


The  Perineum. — Upon  removing  the  deep  layer  of  superficial  peri- 
neal fascia  we  open  into  the  proper  perineal  space. 

Occupying  the  middle  of  the  space  is  a  thin  muscle,  the  bulbo- 
cavernosus;  it  arises  from  the  middle  tendinous  point  of  the  peri- 
neum, and,  passing  forward,  covers  the  bulb  of  the  urethra,  which  is 
the  posterior  enlarged  portion  of  the  corpus  spongiosum,  joining, 


Fig.  182. — The  Perineum  and  Ischio-rectal  Region.  The  superficial  and 
deep  layers  of  the  superficial  perineal  fascia  have  been  removed.  The  space 
in  front  of  the  transversus  perinei  (TP)  corresponds  to  the  perineum;  that 
behind  the  transversus  perinei  to  the  ischio-rectal  region.  The  floor  of  the 
space  {TL)  corresponds  to  the  anterior  layer  of  the  triangular  ligament.  BG, 
bulbo-cavernosus  muscle;  C,  tip  of  coccyx;  GC,  corpus  cavernosum  (crus 
penis) ;  G8,  corpus  spongiosum  (the  posterior  part  of  the  corpus  spongiosum 
is  called  the  bulb  of  the  urethra);  G,  edge  of  gluteus  maximus  muscle;  IG, 
ischio-cavernosus  muscle;  LA,  levator  ani  muscle;  R,  ramus  of  the  pubes 
and  ischium;  SA,  sphincter  ani;  8L,  edge  of  great  sacro-sciatic  ligament; 
TI,  tuberosity  of  the  ischium;  TL,  superficial  or  anterior  layer  of  the  tri- 
angular ligament;  TP,  transversus  perinei  muscle. 


with  fibers  from  the  muscle  of  the  opposite  side  upon  its  upper  sur- 
face, in  a  strong  aponeurosis.  The  most  anterior  fibers  of  the  bulbo- 
cavernosus  muscle  are  attached  on  either  side  to  the  crus  penis,  some 
entirely  encircling  these  bodies  and  joining  upon  the  upper  surface 
of  the  root  of  the  penis  in  such  a  way  as  to  bind  down  the  dorsal 
vessels  of  the  penis,  obstructing  the  return  flow  through  the  vein. 


PERINEUM  AND  ISCHIORECTAL  REGION.  427 

This  muscle  shows  a  median  fibrous  raphe.  Upon  either  side,  arising 
from  the  as'cending  ramus  of  the  ischium,  is  the  ischio-cavernosus. 
The  fibers  of  this  muscle  partly  cover  the  crus  penis,  and  are  attached 
to  its  sheath.  The  crus  penis  is  the  posterior  portion  of  the  corpus 
cavernosum,  and  is  attached  to  the  ramus  of  the  ischium  and  pubes. 

Forming  the  posterior  border  of  this  space  on  either  side  is  the 
transversus  perinei  muscle.  This  muscle  arises  from  the  inner  surface 
of  the  tuberosity  of  the  ischium;  it  passes  inward  and  forward  to  the 
central  tendinous  point  of  the  perineum,  where  it  is  attached,  joining 
with  the  muscle  of  the  opposite  side  and  the  other  muscles  already 
described. 

Passing  forward  through  this  space  are  the  superficial  perineal 
vessels  and  nerve,  and  directed  inward  along  the  border  of  the  trans- 
versus perinei  is  the  transverse  perineal  artery. 

The  floor  of  this  space  is  formed  by  a  dense  layer  of  fascia,  the 
superficial  layer  of  the  deep  perineal  fascia,  or,  better,  of  the  triangular 
ligament.  This  layer  of  fascia  is  perforated  by  the  urethral  canal 
about  one  and  one-half  inches  below  the  symphysis.  Beneath  this 
layer  of  fascia  there  is  a  second  layer,  similar  in  structure,  the  deep 
layer  of  the  deep  j)erineal  fascia  or  triangular  ligament. 

Behind,  corresponding  to  the  transverse  perineal  raphe,  these 
two  layers  of  deep  fascia  are  blended  with  each  other  and  with  the 
deep  layer  of  the  superficial  perineal  fascia.  They  are  attached  later- 
ally to  the  inner  surface  of  the  rami  of  the  pubes  and  ischium;  above, 
in  front,  they  do  not  reach  to  the  symphysis,  but  terminate  in  the 
ligamentum  transversum  pelvis,  a  ligamentous  band  passing  between 
both  pubic  rami,  leaving  a  space  above,  between  it  and  the  symphysis, 
for  the  passage  of  the  vena  dorsalis  penis. 

Between  the  two  layers  of  the  triangular  ligament  the  deep  trans- 
verse perineal  muscle,  the  compressor  urethra?,  is  located;  this  mus- 
cle is  made  up  chiefly  of  striped  muscular  fibers  passing  across  from 
one  pubic  ramus  to  the  other  above  and  below  the  urethra,  and  also 
of  unstriped  fibers  which  pass  in  various  directions,  some  encircling 
the  membranous  part  of  the  urethra. 

The  two  layers  of  the  triangular  ligament,  together  with  the 
muscle  contained  between  them,  form  the  uro-genital  diaphragm.  In 
the  space  between  the  two  layers  of  the  triangular  ligament,  besides 
the  muscle,  are  contained  the  urethra,  its  membranous  portion,  and 
behind,  on  either  side,  Cowper's  gland,  the  duct  of  which  is  seen 
passing  forward  to  enter  the  bulbous  portion  of  the  urethra.     Poste- 


428  URINARY  SYSTEM. 

riorly,  close  to  the  lateral  border  of  the  space,  is  seen  the  internal 
pudic  artery.  It  gives  off  the  artery  of  the  bulb,  and  passing  forward 
divides  into  the  artery  of  the  cms  penis,  which  enters  the  cms,  and 
the  dorsal  artery  of  the  penis,  which  perforates  the  suspensory  liga- 
ment and  runs  forward  along  the  upper  surface  of  the  penis. 

As  the  urethra  perforates  the  superficial  layer  of  the  triangular 
ligament  it  is  provided  with  a  fibrous  prolongation,  which  is  con- 
tinued forward  upon  the  bulb  of  the  urethra. 

The  posterior  or  deep  layer  of  the  triangular  ligament  is  con- 
tinous  (within  the  pelvis)  with  the  fascia  which  covers  the  obturator 
internus  muscle  and  the  upper  or  pelvic  surface  of  the  levator  ani 
muscle,  and  at  the  side  of  the  prostate  it  is  reflected  upward  upon 
this  gland. 

The  prostate  gland,  which  encircles  the  neck  of  the  bladder  and 
contains  the  prostatic  portion  of  the  urethra,  rests  upon  the  upper, 
or  pelvic,  surface  of  the  triangular  ligament  and  the  levator  ani. 

The  levator  ani  serves  to  close  in  that  part  of  the  pelvic  outlet 
which  lies  posterior  to  the  triangular  ligament.  The  anterior  fibers 
of  the  muscle  unite  in  the  middle  line  with  those  of  the  opposite  side 
in  a  sling-like  fashion  to  support  the  prostate.  The  fibers  more  poste- 
riorly are  continued  into  either  side  of  the  rectum  and  to  the  tip  of 
the  coccyx. 

The  seminal  vesicles  and  the  vas  deferens  lie  within  the  pelvis, 
between  the  second  part  of  the  rectum  and  the  base,  or  trigone,  of  the 
bladder,  above  the  upper  border,  or  base,  of  the  prostate.  They  may 
be  brought  into  view  by  separating  the  rectum  from  the  base  of  the 
bladder  and  drawing  it  backward  toward  the  coccyx. 

The  Pelvic  Cavity  from  Within.  —  Examining  the  pelvic  cavity 
from  within,  after  removal  of  the  bladder  and  rectum,  we  find  it 
bounded  in  front  by  the  pubic  bones,  behind  by  the  coccyx  and  sa- 
crum, laterally  by  the  pubes  and  ischium  and  the  sacro-sciatic  liga- 
ments. The  lateral  wall  of  the  pelvic  cavity  is  partly  covered  by  the 
obturator  internus  muscle,  which  arises  from  the  inner  surface  of  the 
pubes  and  ischium  around  the  margin  of  the  obturator  foramen. 

The  obturator  internus  is  covered  by  a  thick  fascia,  which  is  at- 
tached above  to  the  margin  of  the  brim  of  the  pelvis,  being  continuous 
above  with  the  fascia  that  covers  the  psoas  and  iliacus  muscles  (the 
fascia  iliaca).  In  front  this  obturator  fascia  is  continued  into  the 
posterior  or  deep  layer  of  the  triangular  ligament. 

The  obturator  fascia  is  marked  by  a  thick,  white,  fibrous  band, 


PERINEUM  AND  ISCHIORECTAL  REGION.  429 

which  extends  along  the  lateral  wall  of  the  pelvis  from  before  back- 
ward, from  "the  posterior  surface  of  the  pubic  bone  in  front  to  the 
spine  of  the  ischium  behind,  and  is  known  as  the  tendo  arcuatum. 
Along  this  line  upon  either  side  of  the  pelvis  the  levator  ani  takes  its 
origin.  The  muscles  pass  in  a  general  direction  obliquely  downward 
and  inward,  joining  with  each  other  in  the  middle  line.  The  ante- 
rior fibers  pass  downward,  inward,  and  backward,  and  unite  in  the 
middle  line  underneath  the  prostate,  which  they  support  in  a  sling-like 
manner.  The  more  posterior  fibers  pass  downward  and  inward,  and 
are  inserted  into  the  sides  of  the  rectum  just  above  the  anus;  the 
fibers  behind  these  are  attached  to  the  tip  of  the  coccyx. 

Still  more  posteriorly  lies  the  coccygeus.  This  muscle  looks 
like  a  continuation  of  the  levator  ani,  and  serves  to  close  in  the  out- 
let of  the  pelvis  behind  the  levator  ani.  It  is  fan-shaped,  and  is 
attached  by  its  apex  to  the  spine  of  the  ischium  and  by  its  broad 
base  to  the  lateral  margin  of  the  coccyx. 

Lying  upon  the  same  plane,  but  still  farther  above  and  behind, 
and  corresponding  to  the  upper  border  of  the  coccygeus  muscle,  is 
the  pyriformis.  This  muscle  arises  from  the  sides  and  from  the  ante- 
rior surface  of  the  sacrum,  and  passing  outward  leaves  the  pelvis 
through  the  great  sacro-sciatic  notch,  and  closes  the  pelvic  cavity 
behind. 

Thus,  taking  part  in  the  formation  of  the  floor  of  the  pelvis, 
there  is  a  muscular  layer  which  is  formed  in  front  by  the  levatores 
ani,  behind  this  by  the  coccygei,  and  still  farther  behind  and  above 
by  the  pyrif  ormi. 

In  the  front  part  of  the  floor  of  the  pelvis,  between  the  margins 
of  the  levatores  ani,  there  is  a  space  which  corresponds  to  the  poste- 
rior, or  deep,  layer  of  the  triangular  ligament. 

The  fascia  that  covers  the  obturator  muscle,  the  obturator 
fascia,  is  continuous  in  front  with  the  posterior,  or  deep,  layer  of  the 
triangular  ligament;  corresponding  to  the  line,  the  tendo  arcuatum, 
which  marks  the  origin  of  the  levator  ani,  this  obturator  fascia,  which 
is  simply  a  portion  of  the  general  pelvic  fascia,  gives  off  a  layer  that 
covers  the  pelvic  surface  of  the  levator  ani;  farther  back  the  pelvic 
surface  of  the  coccygeus  and  the  pyriformis  and  the  front  of  the 
sacrum  are  also  covered  by  a  continuation  of  this  same  fascia. 

Where  this  fascia,  after  covering  the  pelvic  surface  of  the  levator 
ani,  strikes  the  prostate  and  the  rectum,  it  is  reflected  upward  upon 
the  sides  of  these  organs. 


430  URINARY  SYSTEM. 

A  process  of  this  fascia  is  reflected  inward  between  the  rectum 
and  the  base  of  the  bladder,  and  serves  to  bind  the  seminal  vesicles 
and  vas  deferens  to  the  base  of  the  bladder. 

The  under  surface  of  the  levator  ani,  which  is  directed  toward 
the  perineum  and  ischio-rectal  fossa,  is  also  covered  by  a  thin  layer 
of  fascia,  which  is  derived  from  the  obturator  fascia  along  the  line 
of  the  origin  of  the  levator  ani.    This  is  called  the  anal  fascia. 

The  anal  fascia  is  continued  backward  upon  the  under  surface 
of  the  coccygeus  muscle,  and  anteriorly  is  continued  forward  into  the 
deep  layer  of  the  superficial  perineal  fascia,  joining  along  the  trans- 
verse septum,  or  raphe,  with  all  the  other  fascia?  of  the  perineum. 

OPERATIONS  UPON  THE  PERINEUM,  ETC. 

Perineal  Section  (External  Urethrotomy)  With  a  Guide. — This 
operation  is  performed  for  stricture  of  the  deep  urethra  or  for  the 
purpose  of  draining  the  bladder.  The  patient  is  placed  in  the 
lithotomy  position  and  a  tunneled  sound  introduced  through  the 
urethra  into  the  bladder. 

An  assistant  steadies  the  sound  with  the  right  hand,  throwing 
the  groove  as  much  as  possible  toward  the  surface  of  the  perineum, 
and  at  the  same  time  drawing  the  whole  urethra  upward,  away  from 
the  rectum  toward  the  symphysis.  The  scrotum  is  drawn  up  toward 
the  symphysis,  out  of  the  way  of  the  operator. 

An  incision  is  made  in  the  middle  line  from  the  base  of  the 
scrotum  backward  to  within  a  short  distance  of  the  anus.  This  in- 
cision reaches  through  the  skin  and  fat  down  to  the  deep  layer  of 
the  superficial  perineal  fascia. 

The  edges  of  the  wound  are  drawn  asunder  with  small,  sharp 
retractors,  and  with  another  stroke  of  the  knife  the  deep  layer  of 
the  superficial  perineal  fascia  is  incised  and  the  bulb  of  the  urethra 
exposed  in  the  forward  part  of  the  wound.  Then,  with  the  finger 
in  the  wound,  the  groove  in  the  tunneled  guide  within  the  urethra 
is  recognized  and  the  point  of  the  knife,  guided  upon  the  finger-nail, 
is  placed  in  the  groove  of  the  sound,  piercing  the  membranous  part 
of  the  urethra  just  behind  the  bulb.  The  knife  is  then  shoved  back- 
ward, carrying  the  point  of  the  blade  along  the  groove  of  the  sound 
toward  the  neck  of  the  bladder  and  raising  the  handle,  at  the  same 
time,  toward  the  symphysis.  Having  carried  the  point  of  the  knife 
beyond  the  location  of  the  stricture  into  the  prostatic  portion  of  the 


OPERATIONS  UPON  THE  PERINEUM,  ETC.  43 1 

urethra,  the  handle  is  depressed,  the  knife  at  the  same  time  heing 
withdrawn  and  cutting  as  it  is  withdrawn;  in  this  way  the  mem- 
branous portion  of  the  urethra  is  laid  open  and  the  stricture  divided. 

While  the  urethra  is  being  incised  upon  the  grooved  sound  the 
sound  should  be  lifted  straight  up  toward  the  symphysis,  carrying 
the  urethra  with  it,  and  thus  drawing  it  farther  away  from  the 
rectum.  If  some  urine  or  fluid  is  in  the  bladder,  its  escape  will  demon- 
strate the  fact  that  the  bladder  has  been  entered. 

A  director  gorget  may  now  be  introduced  into  the  bladder  along 
the  groove  of  the  sound  and  the  latter  withdrawn.  A  soft  rubber 
catheter  of  large  caliber  is  introduced  through  the  opening  into  the 
bladder,  and  fixed  in  place  to  the  edge  of  the  incision  in  the  skin 
with  a  silk  stitch,  and  the  wound  then  packed. 

Usually  there  are  no  vessels  to  tie,  although  spurting  arterial 
branches  should  be  clamped  and  twisted  and,  if  necessary,  ligated. 
One  should  avoid  wounding  the  bulb  of  the  urethra  if  possible,  and, 
for  a  certainty,  the  rectum  and  anus. 

Before  dismissing  the  patient,  a  large  metal  sound,  at  least  a 
No.  30  F.,  should  be  passed  through  the  anterior  urethra  and  into 
the  bladder  to  make  certain  that  no  remaining  obstruction  exists  in 
any  part  of  the  canal. 

Perineal  Section  Without  a  Guide. — This  is  a  difficult  procedure. 

All  attempts  to  introduce  a  guide  through  the  constricted  part 
of  the  urethra  into  the  bladder  fail.  One  should  not  be  satisfied  with 
a  single  attempt,  but  should  try,  if  possible,  to  at  least  get  a  small 
whalebone  or  rubber  guide  through.  After  having  made  the  attempt 
and  found  it  impossible  to  get  any  guide  whatever  past  the  stricture, 
a  tunneled  sound  may  be  introduced  as  far  as  the  obstruction. 

As  described  in  the  preceding  operation,  an  incision  is  made  in 
the  perineum  and  the  urethral  canal  opened  upon  the  guide  just  in 
front  of  the  stricture.  After  all  the  bleeding  has  been  arrested,  the 
edges  of  the  wound,  including  the  edges  of  the  incised  urethra,  are 
retracted  with  small,  sharp  hooks,  and  an  effort  then  made  to  find 
the  opening  through  the  stricture  into  the  posterior  part  of  the  ure- 
thra by  inspection  or  by  attempting  to  pass  a  fine  probe-pointed 
director  or  a  fine  whalebone  guide.  At  times  pressure  upon  the 
bladder  will  force  a  few  drops  of  urine  through  the  orifice  of  the 
stricture,  and  this  may  assist  us  in  locating  it  (Koenig). 

If  we  do  not  succeed  in  getting  through  the  stricture  by  these 
means  an  effort  may  be  made  to  open  into  the  urethra  behind  the 


432  URINARY  SYSTEM. 

stricture,  and  then,  if  this  is  successful,  the  stricture  may  be  divided 
from  behind.  It  is  difficult,  however,  to  locate  the  deep  urethra 
(membranous  portion)  without  a  guide.  It  lies  between  the  layers 
of  the  triangular  ligament,  reaching  from  the  bulbous  portion  of  the 
urethra  to  the  apex  of  the  prostate  gland.  Occasionally  the  urethra 
is  diverted  from  the  middle  line  or  a  false  passage  may  be  encount- 
ered which  will  still  further  confuse  us. 

At  times,  especially  if  the  bladder  contains  fluid  and  pressure  be 
made  above  the  pubes,  the  urethra  may  be  felt  as  a  rounded,  com- 
pressible tube,  occupying  the  middle  line  and  perforating  the  tri- 
angular ligament  about  one  and  one-half  inches  below  the  symphysis. 

The  prostatic  urethra,  which  is  the  continuation  of  the  mem- 
branous urethra,  is  surrounded  by  the  prostate  gland,  and,  if  one 
finger  is  introduced  into  the  rectum  and  the  thumb  placed  in  the 
incision  in  the  perineum  the  operator  may  get  the  prostate  between 
them,  and  the  apex  of  the  prostate  may  thus  serve  as  a  clue  to  the 
location  of  the  membranous  urethra.  One  should  refrain  from  blindly 
jabbing  in  the  wound  in  the  hope  of  accidentally  striking  the  urethra. 

If  all  these  measures  fail,  a  suprapubic  cystotomy  may  be  per- 
formed and  a  guide  passed  from  within  the  bladder  into  the  urethral 
canal,  in  this  way  locating  the  posterior  part  of  the  deep  urethra  for 
the  purpose  of  incision. 

If  it  becomes  necessary  to  do  a  suprapubic  cystotomy,  this  may 
be  more  conveniently  done  with  the  patient  in  the  Trendelenburg 
position.  A  suprapubic  cystotomy  under  these  circumstances  is  also 
a  difficult  procedure,  as  the  bladder  may  contain  little  or  no  urine 
and  may  therefore  lie  very  low  in  the  pelvis  behind  the  symphysis. 

Median  Lithotomy. — This  operation  is  performed  for  small  calculi. 
The  bladder  should  be  washed  out  with  boric-acid  solution,  5  or  6 
ounces  being  allowed  to  remain  in  the  bladder.  The  operation  is 
practically  the  same  as  the  preceding  perineal  section  (with  a  guide) 
except  that  the  incision  into  the  urethra  is  made  rather  more  ex- 
tensive, cutting  through  the  anterior  part  of  the  prostatic  as  well  as 
through  the  membranous  portion  of  the  urethra.  The  incision  should 
not  extend  entirely  through  the  prostate.  Oftentimes  after  the  blad- 
der has  been  opened  a  small  stone  will  of  itself  drop  out  of  the 
wound,  or  it  can  be  removed  with  forceps,  scoop,  etc.  It  may  be 
necessary  to  enlarge  the  internal  urethral  orifice  somewhat  with  a 
dilator  or  with  the  finger.  If  necessary,  a  larger  stone  may  be 
crushed  before  removal. 


OPERATIONS  UPON  THE  PERINEUM,  ETC.  433 

The  finger  should  be  introduced  into  the  bladder  to  search  for 
partially  encysted  stones,  etc.  Finally  the  bladder  is  washed  out  and 
a  large,  rubber  catheter  introduced  through  the  perineal  wound  and 
fixed  to  the  edge  of  the  skin  with  a  silk  stitch.  The  wound  is  packed 
about  the  catheter  and  left  open. 

Lateral  Lithotomy. — The  bladder  is  washed  out  with  boric-acid 
solution,  lor  5  ounces  being  left  remaining  in  the  bladder.  A  tun- 
neled sound  is  introduced  through  the  urethra  into  the  bladder  and 
steadied  by  an  assistant.  An  incision  is  made  through  the  skin  and 
fat,  commencing  in  front  at  the  base  of  the  scrotum  and  passing  back- 
ward and  outward  to  a  point  midway  between  the  tuberosity  of  the 
ischium  and  the  anus.  A  second  sweep  of  the  knife  incises  the  deep 
layer  of  the  superficial  perineal  fascia.  The  index  finger  of  the  left 
hand  is  then  introduced  into  the  wound,  and  the  finger-nail  placed  in 
the  groove  of  the  sound  in  the  front  part  of  the  wound,  just  behind 
the  bulb  of  the  urethra.  The  sound  is  then'  drawn  upward  toward  the 
symphysis,  thus  lifting  the  whole  urethra  away  from  the  rectum,  and 
the  point  of  the  knife  placed  in  the  groove  of  the  sound,  cutting 
through  the  membranous  urethra.  The  handle  of  the  knife  is  then 
elevated  and  the  point  shoved  backward  along  the  groove  of  the  guide 
into  the  prostatic  urethra.  The  handle  of  the  knife  is  then  depressed, 
at  the  same  time  withdrawing  the  blade  and  cutting  as  it  is  with- 
drawn. In  this  way  the  membranous  urethra,  together  with  the  side 
of  the  prostate  itself,  are  incised,  the  division  of  these  deep  structures 
being  made  along  the  line  of  the  skin  incision. 

In  making  this  last  incision  upon  the  sound  the  superficial  trans- 
verse perineal  muscle,  and  the  artery  of  the  bulb,  together  with  the 
membranous  urethra,  the  prostate  gland,  and  the  triangular  ligament, 
are  cut.  It  is  usually  necessary  to  clamp  and  tie  the  artery  of  the  bulb, 
and  sometimes,  if  the  incision  extends  too  far  backward  and  outward, 
the  internal  pudic  may  be  divided;  this  branch  bleeds  profusely,  and 
must  be  tied.  After  the  bleeding  has  been  controlled  and  the  stone 
removed,  a  catheter  is  introduced  into  the  bladder  and  fixed  to  the 
edge  of  the  incision.  The  wound  is  packed  about  the  catheter  and 
left  unsutured. 

Prostatectomy  (McGill-Fuller).— The  bladder  is  washed  out  with 
boric-acid  solution,  and  8  or  10  ounces  of  this  allowed  to  remain  in 
the  organ.  A  suprapubic  cystotomy  is  then  done,  as  already  described, 
with  the  patient  in  the  ordinary  position,  lying  upon  the  back.  The 
incision  in  the  abdomen  and  bladder  may  be  held  open  with  long, 


434  URINARY  SYSTEM. 

rather  broad  retractors,  and  the  interior  of  the  bladder  explored.  The 
retractors  are  then  removed  and  the  fingers  of  the  left  hand  introduced 
into  the  bladder,  and  the  wall  of  the  bladder  incised  over  the  enlarged, 
prominent  prostate,  which  is  readily  recognized  by  the  fingers  in  the 
bladder. 

This  incision  is  made  with  long  scissors,  which  are  guided  by  the 
fingers  in  the  bladder,  and  extends  through  the  whole  thickness  of 
the  bladder  wall  into  the  substance  of  the  hypertrophied  prostate;  it 
is  placed  transversely  and  just  behind  the  urethral  orifice,  and  is  made 
sufficiently  large  to  admit  the  finger.  The  finger  is  then  introduced, 
and,  working  between  the  wall  of  the  bladder  and  the  prostate,  the 
entire  hypertrophied  mass  is  enucleated.  While  this  is  being  accom- 
plished the  whole  perineum  is  forced  up  from  below  by  counter-press- 
ure made  in  the  crotch  by  the  closed  fist  of  the  operator  enveloped 
in  a  sterile  towel.  Guiteras  makes  this  counter-pressure  with  two 
fingers  in  the  rectum.  Cutting  forceps  or  a  sharp  spoon  may  be  used 
to  assist  in  the  extirpation  of  the  mass,  although  this  is  usually  un- 
necessary and  undesirable. 

The  hypertrophied  middle  or  lateral  lobes,  or  practically  the 
whole  prostate,  may  be  removed  in  this  way.  The  hemorrhage  is  con- 
siderable, chiefly  oozing,  but  this  is,  as  a  rule,  easily  controlled  by 
irrigating  the  bladder  with  hot  saline  solution. 

The  bladder  may  be  drained  through  the  suprapubic  opening, 
introducing  two  tubes,  as  already  described  for  suprapubic  cystotomy. 
It  is  probably  well,  in  addition,  to  do  a  perineal  section  and  introduce 
a  third  tube  through  the  opening  thus  made  in  order  to  drain  the 
bladder  from  below  (Fuller).  The  perineal  opening  is  readily  made 
upon  a  tunneled  sound.  The  tubes  may  be  left  in  the  suprapubic 
opening  for  several  days  and  fixed  by  the  two  silk  tractor  sutures 
which  are  passed  through  the  wall  of  the  bladder;  if  the  tubes  are 
thus  secured,  one  may  usually  omit  fixing  the  edges  of  the  opening  in 
the  bladder  to  the  margins  of  the  abdominal  incision. 

In  enucleating  the  hypertrophied  prostate  one  should  work  with 
the  fingers  close  to  the  surface  of  the  mass  and  avoid  any  such  force 
as  might  tear  into  the  rectum. 

Prostatectomy  (Alexander).  —  A  suprapubic  cystotomy  is  per- 
formed, and  then  placing  the  patient  in  the  lithotomy  position  a  peri- 
neal section  is  made  and  the  membranous  urethra  opened  back  to  the 
apex  of  the  prostate  (see  "Perineal  Section"). 

The  fingers  of  the  left  hand  are  introduced  into  the  bladder 


OPERATIONS  UPON  THE  PERINEUM,  ETC.  435 

through  the  suprapubic  opeuing,  and  the  enlarged  prostate  pressed 
down  into  the  perineal  wound  and  steadied. 

According  to  Guiteras,  the  prostatic  mass  may  be  pressed  down 
into  the  perineum,  without  opening  the  bladder,  through  an  incision  in 
the  lower  part  of  the  linea  alba  as  for  suprapubic  cystotomy,  with  two 
fingers  in  the  prevesical  space  of  Eetzius. 

The  forefinger  of  the  right  hand  is  introduced  into  the  perineal 
wound,  and,  pushing  the  rectum  backward  away  from  the  prostate, 
we  tear  or  poke  through  the  capsule  of  the  prostate  upon  its  posterior 
inferior  surface  (that  which  presents  toward  the  rectum),  and  then 
with  the  finger  the  whole  of  the  hypertrophied  prostate  may  be  shelled 
out,  working  close  to  the  surface  of  the  mass  so  as  to  avoid  tearing 
through  the  mucous  membrane  of  the  neck  of  the  bladder  and  pro- 
static urethra.  In  this  way  the  lateral  lobes  are  first  enucleated,  and 
then  the  middle  lobe,  if  this  is  also  enlarged,  may  be  removed  in  a 
similar  manner. 

The  hypertrophied  prostatic  mass  may  be  seized  with  vulsella 
forceps  and  traction  made  first  toward  one  side  and  then  toward  the 
other  during  its  enucleation.  The  bladder  is  drained  through  the 
perineal  wound,  but  in  addition  two  tubes  may  be  introduced  through 
the  suprapubic  opening  and  fixed  to  the  edges  of  the  opening  in  the 
bladder;    these  are  allowed  to  remain  for  several  days. 

Prostatotomy  (Bottini's  Operation). — The  apparatus  consists  of 
an  incisore  prostatico  and  a  rheostat  to  regulate  the  current  accu- 
rately. 

One  should  have  previously  made  an  examination  with  the  cys- 
toscope  for  stone,  etc.  The  patient  lies  upon  the  back  with  his  legs, 
hanging  over  the  end  of  the  table  and  the  thighs  spread  apart.  The 
bladder  should  contain  about  6  ounces  of  boric-acid  solution. 

Usually  sufficient  local  anaesthesia  is  obtained  by  the  use  of  a 
solution  of  cocain  which  is  thrown  into  the  urethra  and  stripped 
backward  into  the  posterior  urethra  with  the  finger,  or  a  general 
anaesthetic  may  be  employed.  With  the  finger  in  the  rectum  the 
size  and  the  shape  of  the  prostatic  tumor  may  be  determined. 

The  incisore  is  introduced  into  the  bladder  beyond  the  enlarged 
prostate  and  its  nose  turned  downward  toward  the  base  of  the  blad- 
der, so  that,  as  it  is  slowly  withdrawn,  it  catches  or  hooks  upon  the 
prostatic  mass.  The  extremity  of  the  instrument  may  be  felt  with 
the  finger  in  the  rectum  through  the  bladder  wall  above  the  prostatic 
tumor.    The  instrument  is  now  held  firm  and  steady  in  the  whole  of 


436  URINARY  SYSTEM. 

the  left  hand  and  the  current  closed  and  regulated  by  the  rheostat 
until  sufficiently  strong  to  give  a  red  heat,  which  usually  requires 
fifteen  seconds.  Now,  slowly  turning  the  screw  in  the  handle  of  the 
instrument,  the  heated  blade  is  gradually  withdrawn,  thus  burning 
a  furrow  through  the  prostatic  mass.  If  the  ear  is  held  near  the 
symphysis,  a  sizzling  sound  can  be  heard.  If, -in  withdrawing  the 
blade,  we  note  increased  resistance  in  the  mass,  the  current  is  aug- 
mented; if  too  little  resistance  to  the  blade — if  it  cuts  too  easily — 
the  current  is  correspondingly  diminished.  After  the  incision  has 
been  made  sufficiently  long  the  blade  is  shoved  back  with  a  little 
increase  of  the  current. 

Several  such  channels  or  incisions,  usually  three,  should  be  made 
through  the  prostatic  mass:  one  through  the  middle  line,  toward  the 
rectum,  with  the  nose  of  the  instrument  directed  downward;  one 
with  the  nose  of  the  instrument  directed  upward  toward  the  sym- 
physis; and  one  upon  one  or  both  sides  of  the  middle  line  with  the 
nose  of  the  instrument  again  pointed  downward  toward  the  rectum. 
The  operation  should  occupy  from  five  to  ten  minutes. 

The  incisore  resembles  a  lithotrite,  having  a  male  and  a  female 
blade,  the  male  blade  fitting  into  the  female  and  consisting  of  plati- 
num iridium,  which  may  be  heated  to  any  degree  by  the  electric  cur- 
rent, whose  strength  is  regulated  by  the  rheostat. 

By  turning  the  screw  at  the  handle  the  male  blade  is  withdrawn 
from  the  groove  in  the  female  blade,  and  is  thus  made  to  cut  or  burn 
its  way  through  the  hypertrophied  prostatic  mass. 

The  shaft  of  the  instrument  is  hollow,  so  that  it  may  be  supplied 
with  a  current  of  cold  water,  which  flows  in  through  one  tube  and  out 
through  another;  these  tubes  are  both  placed  near  the  handle.  The 
cold  water  current  is  for  the  purpose  of  keeping  that  part  of  the 
instrument  cool  which  rests  in  the  anterior  part  of  the  urethra. 

Immediately  before  using  the  instrument  it  should  be  tested  with 
the  current,  and  an  observation  made  upon  the  rheostat  to  determine 
just  what  degree  of  current  is  necessary  to  bring  the  blade  to  the 
proper  heat;  usually  about  45  amperes  are  required.  The  screw  in 
the  handle  permits  of  an  incision  up  to  4  cm.  in  length  being  made. 


PART  IX. 

THE  UPPER  EXTREMITY. 


THE  AXILLA. 

The  Axilla  is  a  four-sided  pyramidal  space.  Its  apex  is  above, 
and  corresponds  to  the  depression  upon  the  upper  surface  of  the  first 
rib;,  external  to  the  attachment  of  the  tendon  of  the  scalenus  anticus 
muscle,,  where  the  subclavian  artery  enters  the  axillary  space  to  be- 
come the  axillary.  The  base  of  the  axilla  corresponds  to  the  fold  of 
skin  and  fascia  which  is  stretched  between  the  edge  of  the  pectoralis 
major  in  front  and  that  of  the  latissimus  dorsi  behind. 

The  anterior  wall  of  the  axilla  is  made  up  of  the  pectoralis  major 
and  pectoralis  minor;  the  posterior  wall  is  formed  by  the  subscapularis 
and  the  tendon  of  the  latissimus  dorsi  and  the  teres  major.  The  inner 
wall  corresponds  to  the  side  of  the  chest,  and  is  made  up  of  the  first, 
second,  third,  and  fourth  ribs  and  corresponding  intercostal  muscles 
and  the  upper  serrations  of  the  serratus  magnus.  The  outer  wall  of 
the  axilla  is  a  narrow  space,  which  is  included  between  the  anterior 
and  posterior  walls  and  corresponds  to  the  floor  of  the  bicipital  groove. 
In  the  bicipital  groove  is  lodged  the  long  tendon  of  the  biceps.  The 
coraco-brachialis  muscle,  which  arises  from  the  coracoid  process,  de- 
scends in  the  outer  part  of  the  axillary  space,  lying  close  to  the 
humerus. 

To  the  anterior  lip  of  the  bicipital  groove  is  attached  the  tendon 
of  the  pectoralis  major,  and  to  its  posterior  lip  are  attached  the  ten- 
dons of  the  latissimus  dorsi  and  teres  major. 

The  contents  of  the  axilla  consist  of  the  axillary  artery  and  vein, 
the  large  nerve-trunks  which  are  derived  from  the  brachial  plexus, 
lymphatic  vessels  and  nodes,  and  a  mass  of  loose  connective  tissue  and 
fat  which  is  continuoiis  with  the  connective  tissue  and  fat  of  the  root 
of  the  neck  and  the  mediastinum. 

The  Axillary  Artery. — The  axillary  artery  is  the  continuation 
of  the  subclavian,  and  passes  through  the  axillary  space  from  its  apex 
to  its  base,  where  it  is  prolonged  downward  into  the  arm  as  the  brach- 
ial.    The  vessel  passes  through  the  upper  part  of  the  axillary  space, 

(437) 


438 


UPPER  EXTREMITY. 


lying  close  to  its  anterior  wall.  The  lower,  or  outer,  portion  of  the 
artery  lies  close  to  the  humerus,  beneath  the  edge  of  the  coraco-brachi- 
alis,  resting  upon  the  tendon  of  the  latissimus  dorsi,  and  covered  by 
the  pectoralis  major.  The  axillary  vein,  which  is  sometimes  double, 
accompanies  the  artery,  lying  below  it,  and  both  artery  and  vein  are 
in  close  relation  with  the  nerve-trunks  which  traverse  the  axillary 
space.  With  the  arm  extended  to  a  right  angle,  the  course  of  the 
artery  is  nearly  straight,  and  corresponds  to  an  imaginary  line  which 
is  drawn  from  the  junction  of  the  inner  and  middle  thirds  of  the  clav- 


Fig.  183. — Axillary  Region.  Costo-coracoid  membrane  has  been  cleared 
away  to  show  upper  part  of  the  axillary  vessels,  etc.  C.V.,  cephalic  vein; 
EX. C.N. ,  external  cutaneous  nerve;  IX. C.N. ,  internal  cutaneous  nerve; 
M.N.,  median  nerve;  S.V.,  subscapular  vein;   U.N.,  ulnar  nerve. 

icle  to  a  point  upon  the  front  of  the  elbow  midway  between  the  two 
condyles;  with  the  arm  hanging  by  the  side,  the  artery  describes  a 
curve  which  is  convex  upward  and  outward. 

After  the  pectoralis  major  has  been  separated  from  its  attach- 
ment to  the  clavicle  and  reflected  downward,  the  pectoralis  minor, 
together  with  the  costo-coracoid  membrane,  will  be  exposed.  The 
costo-coracoid  membrane  is  a  rather  thickened  sheath  of  fascia  which 
reaches  from  the  inner  border  of  the  pectoralis  minor  upward,  to  be 
attached  to  the  under  surface  of  the  clavicle  and  to  the  first  rib;  it 
is  simply  a  reflection  of  the  deep  fascia  which  invests  the  pectoralis 


AXILLA.  439 

minor,  and  serves  to  cover  in  the  upper,  or  first,  part  of  the  axillary 
vessels  and  adjoining  structures. 

The  axillary  artery  is  crossed  about  its  middle  by  the  pectoralis 
minor  muscle,  and  may  be  conveniently  considered  in  three  parts. 
The  upper,  or  first,  part  of  the  artery  reaches  from  its  commencement 
at  the  first  rib  to  the  inner  border  of  the  pectoralis  minor,  and  is  not 
exposed  until  after  the  costo-coracoid  membrane  has  been  cleared 
away;  the  second  part  of  the  artery  is  that  portion  which  lies  behind 
the  pectoralis  minor  muscle,  and  the  third  is  that  part  which  reaches 
from  the  outer  border  of  pectoralis  minor  to  the  point  below  where  it 
becomes  the  brachial. 

In  the  first  part  of  its  course  the  three  trunks  of  the  brachial 
plexus  lie  above  the  axillary  artery.  In  the  second  part  of  its  course 
one  trunk  lies  above,  one  behind,  and  one  below  it.  In  the  third  part 
the  cords  of  the  brachial  plexus  communicate  with  each  other,  sur- 
rounding the  axillary  artery,  and  divide  into  a  number  of  branches  to 
supply  the  upper  extremity.  The  median  nerve  lies  external  to  the 
artery,  taking  one  root  from  the  external  cord  of  the  plexus  and  a 
second  root  from  the  internal  cord,  the  latter  root  passing  across  the 
front  of  the  artery.  The  external  cutaneous  nerve  also  lies  to  the 
outer  side  of  the  vessel,  being  derived  from  the  outer  cord  of  the 
plexus.  To  the  inner  side  of  the  artery,  and  derived  from  the  inner 
cord,  are  the  ulnar,  internal  cutaneous,  and  lesser  internal  cutaneous 
nerves.  Derived  from  the  posterior  cord  of  the  brachial  plexus  and 
situated  behind  the  artery  are  the  posterior  circumflex  and  the  mus- 
culo-spiral  nerves.  Immediately  after  its  origin  the  circumflex  passes 
directly  backward  between  the  subscapularis  and  latissimus  dorsi  (and 
teres  major)  muscles,  and  is  distributed  to  the  deep  surface  of  the 
deltoid. 

The  cephalic  vein  pierces  the  costo-coracoid  membrane  and  passes 
across  the  first  part  of  the  axillary  artery  to  empty  into  the  axillary 
vein. 

The  lymphatic  vessels  and  nodes  are  intimately  related  to  the 
axillary  vessels  along  their  whole  course  within  the  axilla. 

From  the  upper,  or  first,  part  of  artery  are  given  off  the  superior 
thoracic  and  acromial  thoracic  branches,  which  are  distributed  to  the 
anterior  wall  of  the  axilla  and  to  the  axillary  contents.  A  branch  from 
the  acromial  thoracic  is  found  in  company  with  the  cephalic  vein  in 
the  groove  between  the  deltoid  and  pectoralis  major  muscles  (Mohren- 
heim's  fossa). 


440  UPPER  EXTREMITY. 

At  the  lower  border  of  the  pectoralis  minor  the  long  thoracic  is 
given  off;  this  branch  passes  downward  close  to  the  lower  border  of 
this  muscle,  lying  beneath  the  edge  of  the  pectoralis  major,  and  ram- 
ifies upon  the  side  of  the  chest. 

Still  lower,  and  close  to  the  posterior  wall  of  the  axilla,  the  artery 
gives  off  the  subscapular,  a  large  branch  which  descends  upon  the 
posterior  wall  of  the  axilla,  along  the  outer  border  of  the  subscapularis 
muscle;  it  is  accompanied  by  the  large  subscapular  nerve,  and  enters 
and  supplies  the  latissimus  dorsi.  External  to  this  branch  is  given 
off  the  posterior  circumflex,  which  passes  backward  between  the  latissi- 
mus dorsi  and  subscapularis  muscles  together  with  the  circumflex 
nerve;  they  wind  around  the  surgical  neck  of  the  humerus  beneath 
the  deltoid,  which  they  supply.  The  axillary  vessels  and  adjoining 
nerves,  etc.,  in  the  upper,  or  inner,  part  of  the  axillary  space,  are 
located  close  to  the  anterior  wall,  and  in  the  lower,  or  outer,  part  of 
the  axilla  they  are  found  close  to  the  humerus,  resting  upon  the 
tendon  of  the  latissimus  dorsi  and  beneath  the  edge  of  the  coraco- 
brachialis.  Branches  of  the  axillary  artery  ramify  upon  the  anterior 
and  posterior  walls  of  the  axillary  space,  and,  descending  upon  the 
inner  wall,  side  of  the  chest,  posteriorly,  is  the  long  thoracic  nerve, 
which  supplies  the  serratus  magnus;  the  middle  of  the  axilla  is, 
therefore,  free  for  incisions  for  abscess,  etc.;  if  it  is  desired  to  ex- 
tirpate completely  the  axillary  contents,  it  is  well  to  commence  by 
making  a  clean  dissection  of  the  main  vessels  and  nerves. 

THE  ARM. 

Upon  the  front  of  the  arm  there  is  seen  a  prominent  spindle- 
shaped  mass,  which  consists  of  the  belly  of  the  biceps  and,  joined  to 
its  inner  side,  the  coraco-brachialis  muscle.  Occup}dng  the  inner  side 
and  back  of  the  arm  is  a  thick  mass  of  muscle,  the  triceps.  Upon  the 
outer  side,  above,  covering  over  the  shoulder-joint,  is  a  large  mass  of 
muscle,  the  deltoid.  Beneath  the  deltoid,  between  it  and  the  surgical 
neck  of  the  humerus,  the  circumflex  nerve  and  the  circumflex  arteries 
are  found.  The  circumflex  nerve,  although  well  protected  by  the  mass 
of  deltoid  muscle,  on  account  of  its  relation  with  the  neck  of  the 
humerus  is  often  injured  by  blows  and  falls  upon  the  shoulder,  with 
a  resulting  disability  of  the  deltoid. 

Vessels  of  Arm.  The  Brachial  Artery. — In  the  depression 
corresponding  to  the  inner  margin  of  the  biceps  and  coraco-brachialis, 


ARM. 


441 


beneath  the  deep  fascia,  lies  the  brachial  artery.  The  brachial  artery 
is  the  continuation  of  the  axillary;  it  passes  down  along  the  inner  side 
of  the  arm  in  the  space  between  the  anterior  muscular  mass,  biceps,  etc., 
and  the  inner  muscular  mass,  triceps;  externally  and  behind,  the 
artery  rests  against  the  humerus,  and  below  the  bend  of  the  elbow  it 
divides  into  the  radial  and  ulnar. 

The  linear  guide  to  the  artery  with  the  arm  abducted  is  a  line 
drawn  from  the  coracoid  process  to  a  point  upon  the  front  of  the 
elbow,  midway  between  the  condyles;  the  muscular  guide  is  the  inner 
edge  of  the  biceps  and  the  coraco-brachialis  muscles. 

The  brachial  artery  is  covered  by  the  integument  and  deep  fascia, 


CEPH/1L 
VEIN 


BRACHIAL 
ARTERY. 

MEDIAE 
filttVE. 

BAC/L- 

/C  VElrf. 


MUS.SPI 


Fig.  184. — Section  through  Middle  of  Right  Arm. 


and  is  accompanied  by  two  veins,  venae  comites,  which  lie  directly 
upon  the  vessel  and  anastomose  with  each  other  by  numerous  trans- 
verse branches.  Above  the  median  nerve  lies  to  the  outer  side  of  the 
artery,  crosses  the  artery  about  its  middle,  and  below  lies  to  its 
inner  side;  the  ulnar  and  internal  cutaneous  nerves  lie  to  the  inner 
side  of  the  artery,  the  ulnar  resting  upon  the  inner  head  of  the 
triceps  and  gradually  getting  farther  away  from  the  artery  as  it 
descends  to  reach  the  back  of  the  internal  condyle.  Behind  the 
artery,  in  the  upper  part  of  the  arm,  lies  the  musculo-spiral  nerve. 

The  basilic  vein  runs  parallel  with  the  brachial  artery,  lying 
superficial  to  it  and  rather  to  its  inner  side.     One  may  meet  this  vein 


442  UPPER  EXTREMITY. 

in  making  the  incision  to  expose  the  brachial  artery.  In  the  lower 
half  of  the  arm  this  vein  is  separated  from  the  artery  by  the  deep 
fascia,  but  about  the  middle  of  the  arm  it  pierces  the  deep  fascia,  and 
thus  gets  into  closer  relation  with  the  artery.  In  the  upper  part  of 
the  arm  the  basilic  vein  joins  the  Tense  comites  to  form  the  axillary 
vein.  Along  the  outer  side  of  the  arm,  superficial  to  the  deep  fascia, 
runs  the  cephalic  vein;  above  this  vein  is  found  in  the  groove  between 
the  pectoralis  major  and  the  deltoid,  and,  after  piercing  the  costo- 
coracoid  membrane,  passes  across  the  first  part  of  the  axillary  artery 
to  empty  into  the  axillary  vein. 

At  the  Elbow,  upon  the  front  aspect  of  the  arm,  there  is  a  tri- 
angular space  with  its  apex  directed  downward  toward  the  hand;  the 
inner  border  of  the  space  is  formed  by  the  pronator  radii  teres,  passing 
obliquely  downward  and  outward  from  the  internal  condyle;  the  outer 
border  is  formed  by  the  spinator  longus,  and  the  floor  of  the  space  by 
the  brachialis  anticus  and  supinator  brevis. 

In  this  space  are  found  the  tendon  of  the  biceps,  the  brachial 
artery  and  its  accompanying  veins,  the  median  and  the  musculo-spiral 
nerves,  and  the  bifurcation  of  the  brachial  artery  into  the  radial  and 
ulnar,  which  occurs  about  one  inch  below  the  bend  of  the  elbow.  In 
this  space  the  median  nerve  is  about  half  an  inch  to  the  inner  side  of 
the  brachial  artery,  owing  to  the  latter's  verging  outward,  away  from 
the  nerve,  toward  the  middle  line. 

The  musculo-spiral  nerve  lies  in  the  outer  part  of  the  space  upon 
the  supinator  brevis,  and  is  covered  by  the  overlapping  edge  of  the 
supinator  longus.  This  region  is  covered  by  the  skin,  superficial  and 
deep  fascia.  The  skin  of  this  region  has  a  marked  tendency  to  retract 
when  cut,  and  this  should  be  remembered  in  marking  out  the  flaps  for 
exarticulation  at  the  elbow-joint.  Lying  just  beneath  the  skin  upon 
the  deep  fascia  is  the  median  cephalic  vein  externally,  and  the  median 
basilic  internally.  The  latter,  the  median  basilic,  is  separated  from 
the  brachial  artery,  not  only  by  the  deep  fascia,  but  also  by  a  fibrous 
expansion  which  is  given  off  from  the  biceps  tendon  to  the  deep 
fascia  of  the  forearm.  The  median  cephalic  is  the  vein  selected  by 
preference  for  intravenous  infusion. 

The  Eadial  Artery.  —  From  its  origin  below  the  bend  of  the 
elbow  the  radial  passes  somewhat  outward  and  then  downward  upon 
the  outer  side  of  the  anterior  aspect  of  the  forearm;  it  lies  superficial, 
though  partly  covered  by  the  overlapping  edge  of  the  supinator  longus. 
In  its  course  it  rests  upon  the  tendon  of  the  biceps,  the  supinator 


ARM.  443 

brevis,  the  radial  origin  of  the  flexor  sublimis  digitorum,  the  pronator 
radii  teres,  the  flexor  longus  pollicis,  and  the  pronator  quadratus.  The 
lower  part  of  the  artery,  above  the  wrist,  lies  beneath  the  integument 
and  the  deep  fascia,  to  the  outer  side  of  the  tendon  of  the  flexor  carpi 
radialis,  between  it  and  the  tendon  of  the  supinator  longus. 

In  the  upper  part  of  the  forearm  the  artery  is  accompanied  by 
the  radial  branch  of  the  musculo-spiral  nerve,  which  lies  to  its  outer 
side.     Usually  two  vena?  comites  accompany  the  artery. 

At  the  wrist  the  radial  artery  curves  around  the  outer  side  of 
the  joint,  lying  beneath  the  extensor  tendons  of  the  thumb  and  resting 
upon  the  external  lateral  ligament;  it  then  passes  across  the  posterior 
surface  of  the  scaphoid  and  trapezium,  and  then  forward,  through  the 
opening  in  the  first  dorsal  interosseous  muscle,  into  the  palm  of  the 
hand. 

In  the  hand  the  radial  artery  is  situated  deep  and  passes  from 
without  inward,  resting  upon  the  bases  of  the  metacarpal  bones  and 
the  anterior  interosseous  muscles,  covered  by  all  the  structures  of  the 
hand:  tendons,  nerves,  superficial  arch,  etc.  Upon  reaching  the  inner 
side  of  the  hand  it  anastomoses  with  the  communicating  branch  from 
the  ulnar,  and  in  this  way  completes  the  deep  palmar  arch.  The  deep 
palmar  arch  is  located  one  finger's  breadth  nearer  the  wrist-joint  than 
the  superficial  palmar  arch.  The  deep  arch  is  accompanied  by  the 
deep  branch  of  the  ulnar  nerve.  From  the  deep  arch  are  given  off 
the  palmar  interosseous  branches;  these  descend  upon  the  interosseous 
muscles  between  the  metacarpal  bones,  and  at  the  clefts  of  the  fingers 
anastomose  with  the  branches  from  the  superficial  arch. 

The  Ulnar  Artery.  —  Immediately  after  its  origin  the  ulnar 
artery  approaches  the  inner  side  of  the  forearm,  passing  deep  beneath 
the  superficial  flexors,  and  lying  upon  the  flexor  profundus  digitorum; 
the  upper  half  of  the  artery  is  thus  covered  by  the  superficial  flexors 
(pronator  radii  teres,  flexor  carpi  radialis,  palmaris  longus,  and  flexor 
sublimis  digitorum);  in  the  lower  half  of  its  course  the  ulnar  artery 
is  still  found  resting  upon  the  flexor  profundus  digitorum,  but  it  is 
rather  more  superficial  and  lies  between  the  tendon  of  the  flexor 
carpi  ulnaris  internally  and  those  of  the  flexor  sublimis  digitorum 
externally.  In  the  forearm  the  artery  is  accompanied  by  the  ulnar 
nerve,  which  lies  to  its  inner  side;  above,  at  its  origin,  the  median 
nerve  lies  to  its  inner  side,  but  soon  this  nerve  crosses  the  artery,  and 
"thus  gets  to  lie  to  its  outer  side.  The  artery  is  accompanied  by  venae 
■comites.    Just  below  its  origin  the  ulnar  gives  off  the  interosseous, 


444  UPPER  EXTREMITY. 

which  divides  into  an  anterior  and  a  posterior  interosseous  branch. 
The  anterior  passes  down  the  front  of  the  forearm,  resting  upon  the 
interosseous  membrane;  the  posterior  passes  through  an  opening  in 
the  upper  part  of  the  interosseous  membrane,  and  runs  down  the 
back  of  the  forearm  between  the  superficial  and  the  deep  layers  of 
muscles. 

At  the  wrist  the  ulnar  artery  lies  superficial,  passing  across  the 
anterior  annular  ligament,  on  the  ulnar  side  of  the  hand,  just  to  the 
radial  side  of  the  pisiform  bone,  with  the  ulnar  nerve  lying  to  its 
inner  side;  here  it  turns  outward  toward  the  radial  side  of  the  hand 


^L  M.LONG. 


^AD.AftT. 


PRON. 
RADII 


BY,. CARPI 

f{AD.LONC- 

/  Cu  n  !  EXTEN.lNDtC. 

EX.OS.METACpa/EX-SKVN/>/ 
E*.PRitA.lNTEF(U.PoL,  IHTER  NO  D.POL 

Fig.  185.— Section  through  Middle  of  Right  Forearm. 

and  anastomoses  with  a  branch  (superficial)  from  the  radial,  thus- 
forming  the  superficial  palmar  arch. 

In  the  hand  the  superficial  palmar  arch  is  about  on  a  level  with 
the  palmar  surface  of  the  thumb,  when  it  is  abducted  and  is  covered 
by  the  skin  and  palmar  fascia,  resting  upon  the  flexor  tendons,  etc.; 
it  gives  off  digital  branches,  four  in  number,  which  pass  downward 
and  after  anastomosing  with  the  palmar  interosseous  branches,  from 
the  deep  palmar  arch,  at  the  clefts  of  the  fingers,  divide  into  two 
branches  to  supply  the  contiguous  sides  of  the  fingers. 

The  superficial  palmar  arch  supplies  all  the  fingers'  except  the 
thumb  and  the  radial  side  of  the  index  finger,  which  are  supplied 
through  branches  from  the  radial. 


HAXD.  445 

The  Musculo-spiral  Xerve. — The  musculo-spiral  nerve  passes 
down  the  back  of  the  arm.  It  is  lodged  in  the  musculo-spiral  groove 
upon  the  posterior  surface  of  the  humerus  between  the  inner  and 
outer  heads  of  the  triceps  muscle  and  covered  by  the  long  head  of 
this  muscle.  In  its  course  it  crosses  the  posterior  surface  of  the 
humerus  obliquely  from  above  downward,  and  from  within  outward, 
and  at  the  elbow-joint  is  found  in  front  of  the  external  condyle  be- 
neath the  supinator  longus.  The  nerve  is  accompanied  by  the  supe- 
rior profunda  branch  of  the  brachial  artery. 

The  Median  Xerye. — In  the  upper  arm  the  median  nerve  is 
closely  related  with  the  brachial  artery.  In  the  forearm  it  lies  be- 
neath the  flexor  sublimis  muscle,  resting  upon  the  flexor  profundus 
digitorum.  Just  above  the  annular  ligament  this  nerve  becomes  more 
superficial,  lying  to  the  inner  side  of  the  tendon  of  the  flexor  carpi 
radialis. 

The  Ulnar  Xerye. — In  the  upper  arm  the  ulnar  nerve  lies  some 
little  distance  to  the  inner  side  of  the  brachial  artery,  resting  upon 
the  inner  head  of  the  triceps,  beneath  the  deep  fascia.  At  the  elbow 
the  ulnar  nerve  lies  behind  the  joint  in  the  groove  between  the  in- 
ternal condyle  and  the  olecranon  process;  it  then  swings  forward, 
and  is  continued  down  the  anterior  aspect  of  the  forearm,  resting 
upon  the  flexor  profundus  digitorum  beneath  the  flexor  carpi  ulnaris 
and  lying  close  to  the  inner  side  of  the  ulnar  artery. 

THE  HAND. 

Beneath  the  integument  in  the  palm  of  the  hand  is  the  palmar 
fascia.  This  is  a  dense,  aponeurotic  layer  intimately  joined  to  the 
integument. 

Beneath  the  palmar  fascia  are  the  flexor  tendons,  superficial  and 
deep  palmar  arches,  nerves,  etc.  As  the  flexor  tendons  pass  across 
the  wrist-joint  into  the  palm  of  the  hand  they  are  bound  down  by 
the  anterior  annular  ligament.  The  extensor  tendons,  as  they  pass 
over  the  back  of  the  wrist-joint  into  the  hand,  are  bound  down  by 
the  posterior  annular  ligament. 

Beneath  the  anterior  annular  ligament  the  flexor  tendons  are 
inclosed  within  a  synovial  sheath,  which  extends  for  a  short  distance 
upward  into  the  forearm  and  downward  into  the  palm  of  the  hand. 
From  this  common  sheath  there  are  given  off  two  processes,  one  of 
which   accompanies   and   envelops  the  tendon   of  the   flexor  longus 


446  UPPER  EXTREMITY. 

pollicis  into  the  thumb;  the  other  accompanies  the  flexor  tendons 
of  the  little  finger  to  their  destination. 

The  sheaths  which  surround  the  tendons  of  the  other  fingers — 
i.e.,  the  index,  middle,  and  ring — do  not,  as  a  rule,  reach  beyond  the 
metacarpophalangeal  articulation,  and  do  not  communicate  with 
this  common  flexor  sheath.  This  fact  is  important  in  determining 
the  extension  of  inflammatory  processes  which  involve  the  tendon 
sheaths  of  the  fingers  up  into  the  hand  and  forearm.  Inflammatory 
processes  which  involve  the  thumb  and  little  finger  are  found  more 
apt  to  extend  into  the  hand  and  forearm  than  those  of  the  other 
fingers. 

The  hand  gets  its  arterial  supply  from  the  radial  and  ulnar  ar- 
teries (see  description  of  these  vessels). 

The  Nerve-supply  of  the  Hand. — The  nerve-supply  of  the  hand 
is  derived  from  the  median  and  ulnar  and  musculo-spiral  nerves. 
The  median  nerve  passes  into  the  palm  of  the  hand  beneath  the 
annular  ligament;  the  ulnar  nerve  passes  into  the  palm  of  the  hand 
across  the  annular  ligament:  i.e.,  in  company  with  the  ulnar  artery. 
In  the  hand,  in  close  relation  to  the  superficial  arch,  the  median  and 
ulnar  nerves  give  off  their  digital  branches,  which  supply  the  in- 
tegument of  the  palmar  aspect  of  the  fingers  with  sensation,  the 
ulnar  supplying  the  little  finger  and  half  the  ring  finger,  the  median 
supplying  the  other  fingers. 

The  dorsal  aspect  of  the  hand  and  the  fifth,  fourth,  and  part 
of  the  third  fingers  are  supplied  by  the  ulnar  nerve;  the  thumb  and 
the  second  and  part  of  the  third  finge-rs  are  supplied  by  the  radial 
nerve,  which  is  a  branch  of  the  musculo-spiral. 

All  the  interossei,  both  anterior  and  posterior,  and  the  two  inner 
lumbricales  are  supplied  by  the  deep  branch  of  the  ulnar  nerve  which 
accompanies  the  deep  palmar  arch;  the  two  outer  lumbricales  are 
supplied  by  the  median. 

A  collection  of  pus  in  the  palm  of  the  hand  may  be  situated 
superficially  beneath  the  skin,  between  it  and  the  palmar  fascia,  or 
deep,  beneath  the  palmar  fascia  or  within  the  proper  synovial  sheaths 
of  the  flexor  tendons. 

Incisions  into  the  palm  of  the  hand  may  be  freely  made  without 
troublesome  hemorrhage,  if  placed  over  the  metacarpal  bones  and 
below  the  line  of  the  superficial  palmar  arch. 

Ligations.  The  Axillaky  Artery. — The  axillary  artery  is  not 
often  exposed  for  the  purpose  of  ligation,  but  frequently  the  artery  and 


LIGATIONS.  447 

vein  and  adjoining  structures  are  laid  bare  during  the  course  of  op- 
erations which  require  a  thorough  cleaning  out  of  the  axilla. 

A  ligature  may  be  applied  to  the  third  part  of  the  axillary  artery 
as  it  lies  upon  the  tendon  of  the  latissimus  dorsi  close  to  the  hu- 
merus. The  arm  should  be  abducted  from  the  side  of  the  chest  to  a 
right  angle  and  slightly  flexed  at  the  elbow-joint,  in  order  that  the 
structures  may  not  be  placed  too  much  upon  the  stretch;  with  the 
arm  in  this  position  the  course  of  the  artery  corresponds  to  a  line 
drawn  from  the  junction  of  the  middle  and  inner  thirds  of  the 
clavicle  to  the  middle  of  the  elbow.  An  incision  two  and  one-half 
inches  long  is  made  through  the  integument  down  to  the  deep  fascia; 
this  incision  is  placed  midway  between  the  anterior  and  posterior 
borders  of  the  axilla,  along  the  edge  of  the  coraco-brachialis  muscle. 
This  incision  penetrates  through  the  skin  and  fat.  With  a  second 
stroke  of  the  knife  the  deep  fascia  is  incised,  and  one  may  then,  with 
the  handle  of  the  knife,  seek  the  white,  shiny  tendon  of  the  latis- 
simus dorsi,  which  is  the  guide  to  the  axillary  vessels  in  this  part 
of  their  course.  When  this  tendon  is  recognized,  it  is  followed  up 
toward  its  attachment  to  the  humerus,  diminishing  the  tension  of 
the  parts  by  flexing  the  arm  somewhat  at  the  elbow,  and  then  the 
vessels  and  nerves  are  readily  located,  the  vein,  which  lies  below  and 
internal  to  the  artery,  being  the  first  structure  encountered. 

The  artery  is  carefully  isolated  for  a  short  distance,  using  blunt 
hooks  to  retract  the  adjacent  structures,  and  the  loose  connective 
tissue  which  immediately  surrounds  the  vessel  is  picked  up  with  a 
toothed  forceps  and  nicked  with  the  point  of  a  knife;  through  the 
small  opening  which  is  thus  made  in  the  connective  tissue  sheath  a 
director  may  be  introduced  between  the  vein  and  the  artery  and 
gradually  worked  around  the  vessel,  taking  care  to  keep  close  to  the 
wall  of  the  vessel,  so  as  not  to  include  any  of  the  adjoining  structures 
— one  should  avoid,  especially,  the  musculo-spiral  nerve,  which  is 
located  behind  the  artery,  upon  the  tendon  of  the  latissimus  dorsi. 
A  small  aneurism  needle  is  then  carried  around  the  vessel,  a  ligature 
passed  through  its  eye,  and  the  needle  withdrawn,  thus  leaving  the 
vessel  surrounded  by  the  ligature,  which  is  tied  with  a  single  square 
knot. 

The  Brachial  Artery. — The  linear  guide  to  the  brachial  artery 
is  a  line  drawn  from  the  coracoid  process  to  a  point  upon  the  front 
of  the  elbow,  midway  between  the  condyles,  the  arm  being  abducted 
to  a  right  angle  with  the  trunk.    The  muscular  guide  to  the  artery  is 


448 


UPPER  EXTREMITY. 


the  inner  edge  of  the  mass  of  muscle,  composed  of  the  biceps  and 
coraco-brachialis. 

The  incision,  two  inches  in  length,  is  made  along  the  inner  bor- 
der of  the  coraco-brachialis,  penetrating  through  the  skin  and  sub- 
cutaneous fat  and  exposing  the  deep  fascia.  At  this  stage,  below 
the  middle  of  the  arm,  the  basilic  vein,  lying  superficial  to  the  deep 
fascia  and  to  the  inner  side  of  the  brachial  artery,  is  met.  In  the 
upper  part  of  the  arm  we  would  not  encounter  the  basilic  vein  until 
after  we  had  cut  through  the  deep  fascia. 

The  deep  fascia  is  now  incised  in  a  direction  corresponding  to 
the  skin  incision,  and  the  bundle  of  structures — which  consists  of 


Fig.  1S6. — Right  Arm.     A,  incision  for  ligation  of  axillary  artery; 
B,  incision  for  ligation  of  brachial  artery. 


the  artery,  vense  comites,  and  adjoining  nerves  and  which  is  readily 
felt  beneath  the  deep  fascia — is  exposed. 

In  the  middle  of  the  arm  we  find  the  median  nerve  lying  upon 
and  crossing  the  artery  from  without  inward;  above  the  middle  of 
the  arm  the  median  nerve  lies  close  to  the  outer  side  of  the  artery; 
below  the  middle  it  lies  along  its  inner  side.  The  ulnar  nerve  is  situ- 
ated upon  the  inner  side  of  the  artery,  getting  farther  away  from  it 
as  it  descends  toward  the  elbow-joint.  The  loose  connective  tissue 
that  surrounds  the  brachial  artery  may  be  now  picked  up  with  a 
mouse-toothed  forceps  and  nicked  with  the  point  of  the  knife; 
through  the  small  opening  thus  made  a  director  is  introduced  and 


LIGATIONS.  449 

gradually  worked  around  the  artery,  which  is  thus  isolated  from  the 
adjoining  structures,  avoiding  the  venae  comites,  which  lie  directly 
upon  it.  A  small  aneurism  needle  is  then  passed  around  the  artery 
through  the  path  made  by  the  director,  and  after  a  ligature  is  car- 
ried through  its  eye  the  needle  is  withdrawn,  leaving  the  artery  sur- 
rounded by  the  ligature,  which  is  tied. 

The  Eadial  Artery.  In  the  Middle  of  the  Forearm.  —  An  in- 
cision one  and  one-half  inches  long  is  made  between  the  middle  and 
inner  thirds  of  the  forearm,  reaching  through  the  skin  and  fat  down 
to  the  deep  fascia;  the  deep  fascia  is  then  incised  and  the  artery  found 
lying  partly  concealed  by  the  overlapping  edge  of  the  supinator  longus, 
which  is  drawn  aside  with  a  retractor.  The  artery  is  accompanied  by 
venae  comites,  which  lie  close  upon  it,  and  also  to  its  outer  side  by  the 
radial  nerve,  which  is  a  branch  of  the  musculo-spiral. 

Just  Above  the  Wrist. — Here  the  artery  is  found  beneath  the  deep 
fascia,  lying  between  the  tendons  of  the  supinator  longus  externally 
and  the  flexor  carpi  radialis  internally.  The  radial  nerve  quits  the 
artery  three  inches  above  the  wrist-joint,  and  is  not  met  with  here. 

The  Ulnar  Artery.  In  the  Middle  of  the  Forearm. — An  in- 
cision one  and  one-half  inches  long  is  made  between  the  middle 
and  inner  thirds  of  the  forearm,  through  the  skin  and  fat  down 
to  the  deep  fascia;  the  deep  fascia  is  then  incised,  and  the  artery 
is  found  lying  beneath  the  edge  of  the  flexor  carpi  ulnaris,  which 
must  be  drawn  inward  to  expose  the  vessel.  The  artery  rests  upon 
the  flexor  profundus  digitorum;  to  the  outer  side  of  the  artery  is  the 
edge  of  the  flexor  sublimis  digitorum.  The  artery  is  accompanied  by 
venae  comites,  which  lie  in  close  relation  with  it.  The  ulnar  nerve  is 
found  upon  the  inner  side  of  the  artery. 

Just  Above  the  Wrist. — The  ulnar  artery  lies  beneath  the  deep 
fascia,  with  the  tendon  of  the  flexor  carpi  ulnaris  to  its  inner  side  and 
the  tendons  of  the  flexor  sublimis  to  its  outer  side;  the  ulnar  nerve 
lies  close  to  the  inner  side  of  the  vessel  in  this  part  of  its  course. 

AMPUTATIONS,  RESECTIONS,  ETC. 

Surgical  Anatomy  of  the  Hand. — The  hand  is  composed  of  the 
carpus,  metacarpus,  and  phalanges.  Each  finger  is  made  up  of  three 
phalanges,  the  thumb  of  two  (see  Fig.  189). 

Phalango-phalaxgeal  Joixts. — The  fingers  are  formed  by  the 
phalanges,  which  articulate  with  each  other,  end  to  end.     Upon  the 


450  UPPER  EXTREMITY. 

anterior  aspect  are  found  the  flexor  tendons;  upon  the  posterior  are 
the  extensor  tendons. 

Each  phalango-phalangeal  joint  has  an  anterior  ligament  and  two 
lateral  ligaments,  the  posterior  ligament  being  formed  by  the  spread- 
out  extensor  tendon. 

Flexion  and  extension  are  permitted  in  these  joints.  Flexion 
occurs  by  the  gliding  of  the  distal  phalanx  around  the  head  of  the 
proximal,  and  therefore  when  the  finger  is  flexed  the  joint  is  found 
below  the  angle  of  the  knuckle  at  a  distance  which  corresponds  to  the 
thickness  of  the  end  of  the  proximal  bone. 

Metacarpophalangeal  Joints. — These  joints  are  quite  simi- 
lar to  the  phalango-phalangeal;  they  are  formed  by  the  articulation  of 
the  heads  of  the  metacarpal  bones  with  the  proximal  ends  of  the 
phalanges.  They  are  provided  with  an  anterior  ligament  and  two 
lateral  ligaments;  the  extensor  tendon  spreads  out  in  the  form  of  a 
broad,  fibrous  sheath  as  it  passes  across  the  posterior  aspect  of  the 
joint,  and  thus  serves  as  a  posterior  ligament,  completely  covering  the 
joint  upon  its  posterior  aspect.  The  anterior  ligaments  are  firmly 
united  with  each  other  (except  that  of  the  thumb),  so  as  to  bind  the 
heads  of  the  metacarpal  bones  firmly  together  into  one  strong,  solid 
row,  which  lends  a  great  element  of  strength  to  the  hand. 

The  lateral  ligaments  are  attached  to  the  bones,  excentrically,  in 
such  a  manner  that,  although  a  considerable  range  of  adduction  and 
abduction  is  allowed  when  the  fingers  are  extended,  this  is  not  per- 
mitted when  they  are  flexed;  when  flexion  takes  place,  the  lateral  liga- 
ments become  relatively  short,  since  the  points  to  which  they  are  fixed 
become  more  widely  separated.  When  flexion  takes  place  between  the 
phalanx  and  the  head  of  the  metacarpal  bone,  it  is  accomplished  by 
the  proximal  end  of  the  phalanx  gliding  around  the  head  of  the  meta- 
carpal bone,  and,  therefore,  in  this  position,  the  level  of  the  joint  will 
be  found  at  a  distance  below  the  angle  of  the  knuckle  which  corre- 
sponds to  the  thickness  of  the  head  of  the  metacarpal  bone. 

EXAKTICULATION    OF    THE    FlNGER   AT    THE    PHALANGO-PHALAN- 

geal  Joint. — In  amputating  a  portion  of  a  finger  an  effort  should 
be  made  to  use  what  integument  may  be  available,  with  a  view  to  pre- 
serving as  much  of  the  length  of  the  finger  as  possible.  No  doubt, 
where  one  may  choose,  the  best  amputation  is  through  a  joint  and  with 
a  long  anterior  flap;  this  brings  the  suture  line  upon  the  posterior 
aspect  of  the  stump  and  out  of  the  way  of  pressure. 

The  end  of  the  finger  which  is  to  be  amputated  is  seized  by  the 


AMPUTATIONS,  KESECTIONS,  ETC.  451 

operator  with  the  left  hand  and  strongly  flexed,  and  a  transverse  in- 
cision, reaching  down  to  the  bone,  is  then  made  across  its  dorsal  sur- 
face, about  one-half  inch  below  the  point  of  the  knuckle;  this  incision 
should  not  include  more  than  one-half  of  the  circumference  of  the 
finger.  An  additional  incision  is  then  made  upon  either  side,  extend- 
ing from  the  end  of  the  transverse  incision,  along  the  side  of  the 
finger,  for  a  distance  corresponding  to  the  length  of  the  proposed  flap, 
and  this  should  also  penetrate  to  the  bone. 

With  the  finger  still  strongly  flexed,  the  joint  is  now  opened 
upon  its  dorsal  aspect,  remembering  that  the  line  of  the  joint  lies 
below  the  point  of  the  knuckle.  After  the  joint  has  been  opened 
the  point  of  the  knife  should  be  passed  in  on  each  side  and  the  lateral 
ligaments  freely  divided,  when  the  joint  surfaces  may  be  separated 


Fig.  187. — Exarticulation  of  the  Finger  at  the  Phalango-phalangeal  Joint. 
The  arrow  indicates  level  of  the  joint  when  the  finger  is  fixed.  Heavy  line 
indicates  the  long  anterior  flap. 


from  each  other.  The  blade  of  the  knife  is  then  introduced  between 
the  joint  surfaces  and  behind  the  bone,  between  the  bone  and  the 
anterior  flap,  and  with  a  sawing  motion  the  anterior  flap  is  cut,  with 
the  edge  of  the  knife  directed  toward  the  bone,  down  to  the  level  of 
the  next  joint,  or  until  a  flap  of  sufficient  length  is  obtained,  when 
it  is  cut  from  within  outward  by  turning  the  edge  of  the  knife  toward 
the  skin.  The  digital  arterial  branch  on  either  side  should  be  tied 
with  catgut.  The  corners  of  the  flap  may  be  rounded  off,  although 
this  is  probably  unnecessary.  The  anterior  flexor  tendons  may  be 
united  by  two  catgut  sutures  to  the  edge  of  the  extensor  tendons,  as 
this  increases  the  probability  of  a  movable,  useful  finger  stump.  The 
edges  of  the  skin  are  approximated  with  two  to  four  catgut  sutures, 
and  the  operation  is  complete. 


452 


UPPER  EXTREMITY. 


EXARTICULATION  OF  THE  FlNGER  AT  THE  METACARPOPHALAN- 
GEAL Joint. — Amputation  through  the  metacarpophalangeal  joint 
may  be  done  with  or  without  the  removal  of  the  head  of  the  meta- 
carpal hone.  Eemoval  of  the  head  of  the  metacarpal  hone  allows  the 
adjoining  fingers  to  be  approximated,  thus  diminishing,  somewhat, 
the  apparent  deformity,  but  this  is  accomplished  at  the  expense  of  the 
solidity  and  strength  of  the  hand;  so  that,  in  most  cases,  especially 
in  laboring  people,  the  end  of  the  metacarpal  bone  is  better  not  re- 
moved. 

The  finger  is  seized  and  flexed  as  in  the  previous  operation,  and 
an  incision  made  upon  the  dorsal  aspect  of  the  hand,  commencing 


Fig.  188. — Exarticulation  of  the  Finger.  A,  incision  for  exarticulation  at 
the  metacarpophalangeal  joint;  B,  incision  for  amputation  of  finger  with 
excision  of  the  head  of  the  metacarpal  bone;  C  indicates  long  anterior  flap  in 
exarticulation  through  the  phalango-phalangeal  joint. 


one-half  inch  above  the  point  of  the  knuckle  and  carried  down  as 
far  as  the  level  of  the  web  of  the  finger.  This  incision  should  pene- 
trate to  the  bone,  dividing  the  skin  and  also  the  aponeurotic  expansion 
of  the  extensor  tendon.  At  the  lower  end  of  this  incision,  upon  a 
level  with  the  web  of  the  finger,  a  second  incision  is  carried  around 
the  finger,  cutting  all  the  structures,  including  the  anterior  and  poste- 
rior tendons,  down  to  the  bone. 

A  corner  of  the  flap  is  now  seized,  the  finger  being  drawn  toward 
the  opposite  side,  and  the  flap,  including  the  tendinous  expansion,  is 
stripped  away  from  the  bone  with  the  knife;  this  is  then  done,  in  a 
similar  manner,  with  the  other  remaining  half  of  the  flap. 

Now  strongly  flexing  the  finger,  the  joint,  which  is  located  a 


AMPUTATIONS,  RESECTIONS,  ETC.  453 

good  one-ha-lf  inch  below  the  angle  of  the  knuckle,  is  opened  by  in- 
serting the  point  of  the  knife,  and  the  lateral  ligament  on  either  side 
is  then  completely  divided.  In  opening  the  joint  and  dividing  the 
lateral  ligaments  the  knife  may  be  grasped  by  the  blade,  being  thus 
held  short  and  firm.  The  bone  is  readily  dissected  out  of  the  flap,  care 
being  taken  not  to  perforate  the  integument  with  the  point  of  the 
knife. 

The  vessels  are  caught  and  tied,  usually  one  on  each  side  of  the 
flap;  the  corners  of  the  flap  may  be  rounded  off  and  the  end  of  the 
bone  covered  by  uniting  the  edges  of  the  flap  with  several  interrupted 
catgut  sutures. 

If,  in  addition,  the  distal  end  of  the  metacarpal  bone  is  to  be 
removed,  the  dorsal  incision  should  be  extended  somewhat  farther 
upward,  toward  the  wrist,  and  through  all  the  structures  down  to  the 
bone.  With  the  point  of  the  knife  the  soft  parts  are  then  separated 
from  the  bone,  and  with  a  strong  cutting  forceps  the  bone  is  divided 
about  one  inch  above  its  lower  end,  taking  care  to  cut  the  bone 
straight  across.  The  loose  lower  end  of  the  bone  is  then  seized  with 
a  toothed  bone  forceps  and  enucleated,  cutting  with  the  edge  of  the 
knife  applied  close  to  the  bone.  After  the  vessels  have  been  ligated, 
the  edges  of  the  flap  are  united  with  interrupted  catgut  sutures.  If 
the  head  of  the  metacarpal  bone  is  taken  away  it  is  not  necessary  to 
make  the  flap  so  long. 

ExAKTICULATION    OF    THE    HAND    AT    THE    CaKPO-METACAKPAL 

Akticulation. — Applicable  to  cases  of  traumatism  where  the  thumb 
can  be  saved. 

The  hand  which  is  to  be  amputated  is  seized  by  the  operator  and 
an  incision  made  which  crosses  the  palm  of  the  hand,  somewhat 
curved,  with  the  convexity  downward  toward  the  fingers;  it  com- 
mences on  the  radial  border  of  the  hand  near  the  head  of  the  meta- 
carpal bone  of  the  index  finger  and  ends  on  the  ulnar  border  of  the 
hand  near  the  base  of  the  fifth  metacarpal  bone.  The  incision  ex- 
tends through  the  soft  parts,  including  the  integument  and  palmar 
fascia,  down  to  the  flexor  tendons.  This  anterior  flap  is  reflected  up- 
ward to  the  level  of  the  carpo-metacarpal  articulation. 

Upon  the  back  of  the  hand  the  incision  extends  through  the  skin 
only,  and  passes  across  the  hand  somewhat  curved,  with  the  concavity 
downward  toward  the  fingers.  If  the  anterior  flap  is  scant,  the  poste- 
rior may  be  made  correspondingly  longer.  The  extremities  of  this 
posterior  incision  join  with  those  of  the  anterior.    The  flexor  tendons 


454 


UPPER  EXTREMITY. 


on  the  front  of  the  hand  and  the  extensors  on  the  back  of  the  hand 
are  now  divided  transversely  down  to  the  bone  with  a  sharp  knife. 
The  hand  is  again  supinated  and  the  carpo-metacarpal  articulation 
opened,  working  from  the  ulnar  side  of  the  hand  toward  the  thumb. 
Care  should  be  taken  in  exarticulating  the  metacarpal  bone  of  the 
index  finger  from  the  trapezoid  not  to  injure  the  joint  between  the 
metacarpal  bone  of  the  thumb  and  the  trapezium. 


Fig.  189.  —  Palmar  Aspect  of  Right 
Hand.  CM,  outline  of  the  palmar  flap 
in  exarticulation  of  the  hand  through 
the  carpo-metacarpal  joint;  D,  incision 
for  exarticulation  of  hand  at  the  wrist- 
joint  (Dubrueil),  front  view. 


Fig.  190.  —  Dorsal  Aspect  of  Right 
Hand.  CM,  dorsal  incision  for  exar- 
ticulation of  the  hand  at  the  carpo- 
metacarpal joint;  D,  incision  for  ex- 
articulation at  the  wrist-joint  (Du- 
brueil), back  view. 


The  branches  of  the  radial  and  ulnar  arteries  must  be  clamped 
and  ligated  before  the  tourniquet  is  removed. 

The  edges  of  the  flaps  are  brought  together  with  interrupted 
catgut  sutures,  the  stump  being  thus  covered  by  the  strong  palmar 
integument,  and  the  suture  line  upon  the  posterior  edge  of  the 
stump  free  from  pressure,  etc. 


AMPUTATIONS,  RESECTIONS,  ETC. 


455 


If  the  condition  of  the  integument  of  the  palm  of  the  hand  is 
such  that  the  longer  flap  cannot  be  taken  from  this  part  of  the 
hand,  then  one  may  get  a  sufficiently  long  flap  from  the  posterior 
surface,  or  two  flaps  of  equal  length,  one  from  the  anterior  and  one 
from  the  posterior  surface  of  the  hand  may  he  made. 

Surgical  Anatomy  of  the  Wrist- joint. — -The  wrist-joint  is  formed 
of  the  first  row  of  the  carpal  hones  in  order,  from  without  inward, 
scaphoid,  semilunar,  and  cuneiform,  and  of  the  lower  extremities  of 
the  radius  and  ulna. 

The  three  carpal  bones  are  united  to  each  other,  and  present 


Fig.  191.— Stump  Result  of  Exarticulation  of  the  Hand  at  the 
Carpo-metacarpal  Joint. 


one  continuous  surface,  smooth,  covered  with  articular  cartilage, 
and  convex  from  side  to  side  and  from  before  backward.  The  outer 
extremity  of  this  surface  slopes  downward  to  a  much  lower  level 
than  the  inner  extremity. 

The  articular  surface  presented  by  the  lower  ends  of  the  radius 
and  ulna  is  concave  in  order  to  accommodate  the  convex  articular 
surface  of  the  upper  row  of  carpal  bones.  This  radio-ulnar  articular 
surface  is  directed  obliquely  downward  externally,  so  that  the  outer, 
or  radial,  end  is  a  considerable  distance  below  the  level  of  the  inner, 
or  ulnar,  end,  and  is  continued  into  the  external  styloid  process,  to 
the  tip  of  which  the  external  lateral  ligament  is  attached;  the  inner, 


456  UPPER  EXTREMITY. 

or  ulnar,  side  of  this  radio-ulnar  articular  surface  presents  the  inner 
styloid  process,  prolonged  from  the  lower  end  of  the  ulna.  The  tip 
of  this  process  gives  attachment  to  the  internal  lateral  ligament  of 
the  wrist-joint. 

Of  the  three  carpal  hones,  the  outer  two.  the  scaphoid  and 
semilunar,  correspond  to  and  articulate  with  the  radial  articular 
surface;  the  inner,  the  cuneiform,  corresponds  to  the  ulnar  articular 
surface,  an  interarticular  fihro-cartilage  being  interposed  between 
them. 

There  is  a  broad  anterior  and  a  broad  posterior  ligament,  and 
these,  together  with  the  lateral  ligament  on  either  side,  practically 
form  a  capsular  ligament,  which  is  lined  upon  its  inner  aspect  by  a 
thin,  serous  layer,  the  synovial  membrane  of  the  joint. 

EXAETICULATION     OF    THE    HAND    AT    THE     WBIST-JOINT     (Du- 

betieil). — An  assistant  steadies  the  forearm,  drawing  the  integument 
rather  toward  the  elbow.  The  hand  which  is  to  be  amputated  is 
seized  by  the  operator,  and  commencing  upon  the  front  of  the  wrist, 
between  the  middle  and  outer  thirds,  an  incision  is  made,  which  is 
carried  inward  around  the  inner  border  of  the  wrist,  below  the  level 
of  the  styloid  process,  and  across  the  back  of  the  wrist,  terminating 
at  a  point  between  the  middle  and  outer  thirds  and  directly  opposite 
the  point  where  the  incision  commenced.  This  incision  should  ex- 
tend through  the  skin  and  subcutaneous  fatty  tissue  and  should  be 
placed  well  below  the  level  of  the  wrist-joint;  otherwise,  after  the 
integument  has  retracted,  the  cut  edge  will  be  found  to  be  above 
the  level  of  the  wrist-joint. 

A  tongue-shaped  flap,  with  its  base  corresponding  to  the  radial 
third  of  the  circumference  of  the  wrist,  is  now  marked  out  by  an 
incision  reaching  from  either  end  of  the  circular  incision  described 
above.  This  flap  of  integument  is  taken  from  over  the  metacarpal 
bone  of  the  thumb,  its  lower  extremity  corresponding  to  the  meta- 
carpo-phalangeal  articulation  of  the  thumb  (see  Fig.  189).  This  flap, 
including  the  superficial  fascia  and  fat,  is  dissected  back  to  the  level 
of  the  wrist-joint.  The  wrist-joint  is  then  entered  by  introducing 
the  blade  of  the  knife  into  the  joint  on  its  radial  side,  below  the 
styloid  process,  and  the  hand  severed  from  the  forearm,  thus  com- 
pleting the  exarticulation. 

The  radial  and  ulnar  arteries  are  picked  up  and  ligated,  the 
median  and  ulnar  nerves  seized  and  cut  short,  and  the  ends  of  the 
bones  covered  over  with  the  flap,  which  is  fixed  with  interrupted 


AMPUTATIONS,  RESECTIONS,  ETC.  457 

catgut  sutures.  The  first  stitch  should  unite  the  apex  of  the  tongue- 
shaped  flap  to  the  skin  at  a  point  corresponding  to  the  tip  of  the 
styloid  process  of  the  ulna,  and  the  other  stitches  are  then  placed 
so  as  to  distribute  the  flap  evenly,  should  it  he  found  to  be  a  little 
redundant. 

An  analogous  operation  may  be  done  at  the  wrist-joint,  taking 
the  tongue-shaped  flap  of  integument  from  the  ulnar  side  of  the 
hand. 

One  may  also  exarticulate  at  the  wrist-joint,  using  two  flaps, 
an  anterior  and  a  posterior  flap,  of  equal  length;  or  else  one  long, 
preferably  the  anterior,  and  one  short;  or  the  circular  method  may  be 
used. 

Amputation  through  the  Forearm. — The  forearm  is  a  good  place 
at  which  to  practice  the  old  musculo-tegumentary  flap  method. 
Practically,  this  method  is  now  almost  entirely  discarded  in  favor 
of  the  skin  flap  or  circular  method.  The  arm  overhangs  the  edge 
of  the  table.  The  hand,  which  is  supinated,  is  supported  by  an 
assistant.  A  long,  sharp  amputating  knife  is  introduced  through 
the  skin  upon  the  outer  side  of  the  forearm,  at  the  level  where  it 
is  intended  to  divide  the  bones,  until  its  point  touches  the  outer 
surface  of  the  radius;  it  is  then  pushed  through  the  soft  parts  upon 
the  front  of  the  forearm,  keeping  close  to  the  anterior  surface  of  the 
bones,  and  emerging  at  a  corresponding  point  upon  the  inner,  or 
ulnar,  side  of  the  forearm.  Now,  with  a  sawing  motion  and  with 
the  edge  of  the  knife  directed  toward  the  radius  and  ulna,  the  ante- 
rior flap  which  includes  the  integument  and  all  the  muscular  tissue, 
is  cut  away  from  the  bones.  If  the  anterior  and  posterior  flaps  are 
to  be  of  equal  length,  each  flap  should  correspond  in  length  to  one- 
half  the  diameter  of  the  limb,  at  the  point  where  the  bones  are  to 
be  divided,  plus  one-third  extra,  which  is  allowed  for  retraction. 
When  the  flap  has  been  cut  to  a  sufficient  length,  the  edge  of  the 
knife  is  turned  toward  the  integument  and  the  flap  cut  square  from 
within  outward. 

The  posterior  flap  is  formed  in  a  similar  manner.  The  point  of 
the  knife  is  again  introduced  upon  the  outer,  or  radial,  side  of  the 
forearm  in  the  upper  angle  of  the  incision  which  marks  the  anterior 
flap,  and  thrust  through  the  forearm  behind  the  bones,  between  them 
and  the  soft  parts,  emerging  at  the  upper  part  of  the  incision  upon 
the  inner,  or  ulnar,  side  of  the  forearm,  and  then,  with  the  edge  of 
the  knife  closely  applied  to  the  bones,  the  posterior  flap  is  cut  equal 


453  UPPER  EXTREMITY. 

in  length  to  the  anterior.  The  flaps  should  be  square,  and  not 
tongue-shaped. 

The  flaps  are  turned  hack  and  held  thus  by  the  hands  of  an 
assistant  or  with  sharp  retractors,  or  by  the  operator.  "With  a  scalpel 
the  interosseous  membrane  is  cut  through  and  the  bones  cleaned  of 
any  remaining  soft  parts,  in  order  to  make  way  for  the  saw. 

The  heel  of  the  saw  is  placed  upon  one  of  the  bones,  and  by 
drawing  it  backward  firmly  and  steadily  a  groove  is  made,  after  which 
the  bones  can  be  rapidly  severed,  engaging  the  second  bone  after 
the  first  has  been  partly  sawn  through,  and  completing  the  section 
of  both  simultaneously.  No  cloth  retractor  is  necessary,  the  flaps 
being  held  back  by  the  operator's  hand  while  he  saws  through  the 
bones. 

In  the  dead  subject  it  will  be  seen  that  the  muscles  in  the  flap 
protrude  beyond  the  edge  of  the  integument;  this  is  due  to  the  un- 
equal retraction  of  skin  and  muscle,  and  does  not  occur  to  the  same 
degree  in  the  living  subject.  Should  the  ends  of  the  muscles  or  ten- 
dons protrude,  they  may  be  trimmed  off  with  the  scissors. 

The  radial  and  ulnar  arteries  are  sought  for  and  ligated;  also 
the  anterior  and  posterior  interosseous.  These  latter  are  found  close 
to  the  anterior  and  posterior  surfaces,  respectively,  of  the  interos- 
seous membrane.  The  median  and  ulnar  nerves  should  be  drawn 
down  and  cut  short.  The  edges  of  the  flap  are  joined  all  around 
with  interrupted  catgut  sutures. 

We  may  amputate  through  the  forearm,  using  skin  flaps,  ante- 
rior and  posterior,  of  equal  length,  or  one  long  and  the  other  short; 
or  we  may  reflect  a  circular  tegumentary  cuff,  in  all  of  these  opera- 
tions, dividing  the  muscles  on  a  level  with  or  just  below  the  point 
at  which  the  bones  are  to  be  divided. 

Surgical  Anatomy  of  the  Elbow-joint.  —  The  elbow-joint  is  an 
irregular,  rather  complicated  joint,  formed  by  the  lower  end  of  the 
humerus  and  the  upper  end  of  the  radius  and  ulna. 

The  lower  end  of  the  humerus  is  broad  from  side  to  side  and 
flattened  from  before  backward,  and  presents  below  two  partially 
separated,  smooth,  rounded,  articular  surfaces,  the  smaller,  outer 
one  being  for  articulation  with  the  radius,  and  the  broader,  inner 
one  for  articulation  with  the  ulna.  The  plane  of  this  double  artic- 
ular surface  is  oblique  from  without  downward  and  inward,  its  inner 
end  being  on  a  much  lower  level  than  its  outer. 

The  surface  for  articulation  with  the  radius,  the  external,  is  a 


AMPUTATIONS,  RESECTIONS,  ETC.  459 

portion  of  a.  sphere,  and  occupies  the  lower  and  anterior  aspect  of 
the  humerus. 

The  surface  with  which  the  ulna  articulates,  the  inner,  is  broad, 
spool-shaped,  and  occupies  not  only  the  anterior  and  inferior,  but 
also  the  posterior,  aspect  of  the  bone.  This  portion  articulates  with 
the  greater  sigmoid  cavity  of  the  ulna. 

Below,  the  joint  is  formed  by  the  upper  end  of  the  radius  ex- 
ternally and  the  upper  end  of  the  ulna  internally.  The  upper  end 
or  head  of  the  radius  presents  a  shallow  cup-shaped  surface,  covered 
with  cartilage  for  articulation  with  the  radial  part  of  the  articular 
surface  of  the  humerus;  this  surface  is  surrounded  by  a  smooth, 
narrow  margin,  which  rotates  within  the  ring  formed  by  the  lesser 
sigmoid  cavity  of  the  upper  end  of  the  ulna  and  the  orbicular  liga- 
ment. 

The  head  of  the  radius  lies  just  below  the  external  condyle,  and 
may  be  recognized  even  when  the  joint  is  considerably  swollen;  by 
supinating  and  pronating  the  hand  it  may  be  felt  to  rotate  beneath 
the  skin.  The  elbow-joint  is  readily  entered  between  the  head  of 
the  radius  and  the  external  condyle. 

The  upper  extremity  of  the  ulna  is  irregular,  and  presents  an 
articular  surface,  the  greater  sigmoid  cavity,  which  is  made  up  of 
the  superior  surface  of  the  upper  end  of  the  ulna  and  the  anterior 
surface  of  the  olecranon  process.  The  olecranon  is  a  strong,  square- 
shaped  process  of  bone  which  projects  upward  from  the  posterior 
part  of  the  upper  end  of  the  ulna.  The  greater  sigmoid  cavity  is 
covered  by  articular  cartilage  and  articulates  with  the  trochlear  sur- 
face of  the  lower  end  of  the  humerus.  The  upper  end  of  the  ulna 
further  presents,  upon  its  outer  edge,  a  smooth  depression,  the  lesser 
sigmoid  cavity,  to  either  end  of  which  the  orbicular  ligament  is 
attached.  Within  the  ring  formed  by  the  orbicular  ligament  and 
the  lesser  sigmoid  cavity  the  upper  end  of  the  radius  rotates  in 
pronation  and  supination. 

Besides  the  parts  entering  directly  into  the  formation  of  the 
elbow-joint  there  may  be  felt,  internally,  the  internal  epicondyle, 
very  prominent  and  giving  attachment,  upon  its  anterior  aspect,  to 
the  common  tendon  of  origin  of  the  flexor  muscles  of  the  forearm, 
and,  externally,  the  less  prominent  external  epicondyle,  giving  at- 
tachment, upon  its  posterior  aspect,  to  the  common  tendon  of  the 
extensor  muscles  of  the  forearm.  Behind  may  be  felt  the  prominent 
olecranon  process.    At  its  junction  with  the  ulna  the  olecranon  proc- 


460  UPPER  EXTREMITY. 

ess  is  somewhat  constricted,  and  is  here  often  the  site  of  fracture. 
Its  anterior  surface  enters  into  the  formation  of  the  elbow-joint, 
forming  the  upper  part  of  the  greater  sigmoid  cavity.  Its  posterior 
surface  is  subcutaneous  and  triangular  in  shape,  with  its  apex  below, 
where  it  is  continuous  with  the  posterior  border  of  the  shaft  of  the 
ulna.  To  the  broad,  upper  border  of  the  olecranon  process  is  at- 
tached the  triceps  tendon,  and  around  its  margin  the  posterior  and 
lateral  ligaments  of  the  joint.  The  upper  border,  or  surface,  of  the 
olecranon  process,  when  the  arm  is  extended,  is  on  a  line  drawn  be- 
tween the  two  epicondyles. 

The  elbow-joint  is  provided  practically  with  a  capsular  liga- 
ment, which  is  lined,  upon  its  inner  surface,  by  a  synovial  membrane 
which  also  dips  into  that  part  of  the  joint  between  the  head  of  the 
radius  and  the  lesser  sigmoid  cavity  of  the  ulna  and  orbicular  liga- 
ment. 

The  ulnar  nerve  lies  in  close  relation  with  the  elbow-joint,  poste- 
riorly, in  a  groove  between  the  internal  epicondyle  and  the  olecranon 
process. 

ExAKTICULATIOX     OF     THE      FOREARM     AT      THE      ELBOW-JOIXT 

(Double  Circular  Method). — The  arm  overhangs  the  side  of  the 
table,  and  is  steadied  by  an  assistant,  who  draws  the  integument 
somewhat  toward  the  shoulder-joint.  The  operator  grasps  the  limb 
with  the  left  hand,  and  with  a  long  amputating  knife  a  circular  in- 
cision is  made  around  the  forearm,  through  the  skin  and  fat  down 
to  the  deep  fascia.  This  incision  should  be  placed  below  the  level 
of  the  elbow-joint  a  distance  corresponding  to  one-half  the  diameter 
of  the  arm  at  the  elbow-joint,  plus  one-third  extra,  which  is  allowed 
for  shrinkage  of  the  skin.  The  upper  surface  of  the  head  of  the 
radius  marks  the  level  of  the  elbow-joint.  This  tegumentary  flap  is 
dissected  away  from  the  deep  fascia  and  reflected  upward  like  a 
turned-up  cuff  as  far  as  the  level  of  the  elbow-joint.  At  this  level 
the  muscles  are  divided  with  the  long  knife  down  to  the  bone,  and 
the  elbow-joint  then  entered  externally  above  the  head  of  the  radius, 
finally  passing  in  between  the  ulna  and  the  humerus,  cutting  the 
anterior  and  lateral  ligaments.  The  forearm  then  hangs  suspended 
by  the  attachment  of  the  triceps  tendon,  and,  this  being  cut  close  to 
the  olecranon,  the  exarticulation  is  complete. 

In  this  operation  a  common  fault  is  that  the  muscles,  being  cut 
on  a  level  with  the  elbow-joint,  retract  and  leave  the  end  of  the 
humerus  projecting  into  the  wound.    Even  if  the  muscles  are  divided 


AMPUTATIONS,  RESECTIONS,  ETC.  461 

a  considerable  distance  below  the  level  of  the  joint  and  stripped 
away  from  the  bone  from  a  point  below  the  level  of  the  joint,  it  helps 
but  little,  as,  upon  the  posterior  aspect,  there  are  no  muscles,  and 
even  the  tendon  of  the  triceps,  when  cut  close  to  the  olecranon,  lies 
well  above  the  level  of  the  joint;  therefore,  in  most  cases,  it  is  de- 
sirable to  supplement  this  operation  by  resecting  the  lower  articular 
end  of  the  humerus,  which  may  be  readily  done.  As  regards  the 
usefulness  of  the  resulting  stump,  it  matters  little  if  we  make  the 
section  just  above,  instead  of  through,  the  elbow-joint. 

It  is  necessary  to  ligate  the  brachial  artery  and  its  accompanying 
vein  separately.  The  median,  ulnar,  and  musculo-spiral  nerves  are 
drawn  down  and  cut  short.  The  edges  of  the  skin  are  united  from 
side  to  side  with  interrupted  catgut  sutures,  and  a  small  drain  intro- 
duced, which  may  be  removed  after  forty-eight  hours. 

Amputation  of  the  Arm. — Here  the  double  circular  method  is 
preferable.  The  arm,  hanging  over  the  side  of  the  table,  is  grasped 
above,  near  the  shoulder,  by  an  assistant,  who,  at  the  same  time  that 
he  steadies  the  arm,  draws  the  integument  somewhat  toward  the 
shoulder.  With  a  long  amputating  knife  a  circular  incision  is  made, 
which  reaches  through  the  skin  and  superficial  fascia  down  to  the 
deep  fascia.  This  incision  should  be  placed  below  the  level  at  which 
the  bone  is  to  be  divided  a  distance  equal  to  one-half  the  diameter 
of  the  arm,  plus  one-third,  which  is  allowed  for  retraction  of  the 
skin. 

The  circular  flap,  which  includes  all  the  fatty  tissue,  but  not  the 
deep  fascia,  is  now  dissected  back  like  a  cuff  to  a  point  one  inch 
below  the  level  at  which  the  bone  is  to  be  divided;  at  this  point 
the  muscles  are  severed  down  to  the  bone  with  one  circular  sweep 
of  the  long  knife. 

With  a  blunt  elevator  or  the  back  of  the  scalpel  the  muscles, 
but  not  the  periosteum,  are  separated  from  the  humerus  for  another 
inch,  and  thus  the  level  is  reached  at  which  the  bone  is  to  be  divided. 
After  the  periosteum  has  been  cut  by  drawing  the  knife  around  the 
bone,  the  heel  of  the  saw  is  applied  and  with  a  firm  backward  move- 
ment a  groove  is  made  in  which  the  saw  may  work,  and  then  the  bone 
is  rapidly  severed. 

While  sawing  the  bone  it  is  unnecessary  to  use  a  cloth  retractor, 
as  the  soft  parts  may  be  held  back  so  as  to  give  the  saw  freedom,  by 
the  hands  of  an  assistant,  or  with  two  sharp  retractors. 

Having  completed  the  amputation,  it  will  be  seen  that  the  mus- 


462 


UPPER  EXTREMITY. 


cles  slightly  overhang  the  end  of  the  bone  without  covering  it,  and 
that  the  skin  flap  is  sufficiently  long  to  cover  the  whole  stump. 

The  brachial  artery  and  accompanying  veins  are  found  lying 
anterior  and  internal  to  the  bone,  and  should  be  clamped  and  tied; 


Fig.  192.— Right  Arm,  Anterior  Aspect.  A,  outline  of  the  lateral  deltoid 
flap  in  exarticulation  at  the  shoulder-joint;  B,  amputation  through  the  arm; 
1,  incision  through  the  skin;  2,  incision  through  the  muscle;  3,  line  of  division 
through  the  bone;  G,  incision  for  exarticulation  through  the  elbow- joint 
(circular  method). 


the  median  and  ulnar  nerves,  which  are  in  close  proximity  to  the 
brachial  artery,  should  be  cut  short;  likewise  the  musculo-spiral, 
which  is  found  upon  the  posterior  surface  of  the  humerus.  The  supe- 
rior profunda,  a  branch  of  the  brachial  artery,  which  accompanies  the 


AMPUTATIONS,  EESECTIONS,  ETC.  463 

musculo-spiral  nerve,,  is  also  seized  and  ligated.  The  tourniquet  is 
then  removed  and  any  remaining  bleeding  vessels  clamped  and 
ligated. 

The  edges  of  the  skin  are  united  from  side  to  side,  making  a 
transverse  line,  by  several  interrupted  catgut  sutures;  if  the  wound 
is  clean,  one  may  omit  drainage,  or  a  temporary  drain  may  be  intro- 
duced, and  removed  after  forty-eight  hours. 

The  arm  may  also  be  amputated  with  the  formation  of  musculo- 
tegumentary  flaps,  as  described  for  the  forearm,  or,  instead  of  a  cuff 
skin  flap,  one  may  use  lateral  or  antero-posterior  skin  flaps  of  equal 
length,  or  one  long  and  the  other  short. 

Surgical  Anatomy  of  the  Shoulder- joint.  —  The  shoulder- joint 
consists  of  the  articulation  of  the  upper  end  of  the  humerus  and  the 
glenoid  cavity  of  the  scapula.  The  articular  surface  of  the  upper 
end  of  the  humerus  looks  inward  and  backward  and  is  hemispheroidal 
in  shape;  it  presents  the  arc  of  a  smaller  sphere  from  before  back- 
ward, and  of  a  larger  sphere  from  above  downward;  that  is,  the 
diameter  from  before  backward  is  shorter  than  that  from  above 
downward. 

The  articular  surface  is  limited  by  the  anatomical  neck,  which 
is  narrow  and  well  marked  above,  but  broad  and  less  well  marked 
below;  the  anatomical  neck  marks  the  junction  of  the  head  of  the 
bone  with  the  shaft. 

Externally  may  be  observed  the  broad,  large  tuberosity  major; 
internally  and  below  the  head  is  the  smaller  tuberosity,  the  tuber- 
osity minor.  To  the  tuberosity  minor  is  attached  the  tendon  of  one 
muscle,  the  subscapularis;  to  the  tuberosity  major — i.e.,  to  its  upper 
and  posterior  borders — are  attached  the  tendons  of  three  muscles: 
the  supraspinatus,  the  infraspinatus,  and  the  teres  minor,  in  that 
order  from  above  downward. 

The  anterior  border  of  the  greater  tuberosity  forms  the  exter- 
nal border  of  the  bicipital  groove,  the  external,  or  anterior,  bicipital 
ridge;  the  lesser  tuberosity  and  the  ridge  that  is  prolonged  down- 
ward from  it  forms  the  inner  border  of  the  bicipital  groove,  the  in- 
ternal, or  posterior,  bicipital  ridge.  Between  the  two  is  the  bicipital 
groove. 

To  the  external  bicipital  ridge  is  attached  the  tendon  of  the 
pectoralis  major;  to  the  internal  bicipital  ridge  are  attached  the 
tendons  of  the  latissimus  dorsi  and  teres  major.  Lying  in  the  groove 
itself,  held  in  place  by  a  process  of  fibrous  tissue,  is  the  long  tendon 


461  UPPER  EXTREMITY. 

of  the  biceps  muscle.  Close  to  the  humerus,  between  the  tendon  of 
the  pectoralis  major  in  front  and  the  tendons  of  the  latissimus  dorsi 
and  teres  major  behind,  are  the  brachial  vessels  and  accompanying 
nerves,  which  descend  in  a  bunch  from  the  axilla,  partially  overlapped 
by  the  coraco-brachialis  muscle.  The  bicipital  groove  really  forms 
the  outer  wall  of  the  axilla  when  the  arm  hangs  by  the  side. 

Below  the  tuberosities  is  the  surgical  neck,  so  called  because  it 
is  a  rather  common  site  of  fracture. 

The  glenoid  cavity,  a  depressed  area  upon  the  head  of  the  scap- 
ula, is  much  less  extensive  in  area  than  the  articular  surface  pre- 
sented by  the  humerus;  it  is  shallow,  longer  from  above  downward 
than  from  before  backward,  and  is  connected  with  the  body  of  the 
scapula  by  the  neck. 

The  glenoid  cavity  presents  a  slightly  raised  margin,  to  which 
margin  is  attached  the  glenoid  ligament,  which  serves  to  deepen  the 
cavity. 

Overhanging  the  shoulder- joint  is  the  acromion  process,  the 
extreme  outer  end  of  the  spine  of  the  scapula;  this  process  articulates 
with  the  outer  end  of  the  clavicle,  and  forms  the  prominent  outer 
part  of  the  shoulder-girdle  and  a  protecting  ledge  over  the  shoulder- 
joint. 

In  front  and  internal  to  the  shoulder-joint  the  coracoid  process 
may  be  felt,  and  in  thin  subjects  seen;  it  projects  forward  from  the 
upper  border  of  the  scapula,  lying  below  the  outer  end  of  the  clavicle, 
to  the  under  surface  of  which  it  is  connected  by  strong  ligaments. 
Passing  from  the  coracoid  to  the  acromion  process  is  a  strong  liga- 
mentous band,  the  coraco-acromial  ligament.  This  ligament  passes 
over  the  head  of  the  humerus,  across  the  upper  part  of  the  shoulder- 
joint,  deepening  the  cavity  in  which  the  head  of  the  humerus  plays 
and  serving  to  add  strength  to  the  joint. 

The  shoulder-joint  is  provided  with  a  capsular  ligament,  which 
is  attached  above  to  the  neck  of  the  scapula  around  the  glenoid 
cavity,  and  below  to  the  anatomical  neck  of  the  humerus.  A  sepa- 
rate fibrous  band,  called  the  coraco-humeral  ligament,  extends  from 
the  coracoid  process  down  to  the  neck  of  the  humerus,  where  it  is 
attached  in  common  with  the  capsular  ligament,  of  which  it  is  really 
a  part. 

The  long  tendon  of  the  biceps  is  attached  to  the  upper  margin 
of  the  glenoid  cavity;  it  passes  across  the  upper  surface  of  the  head 
of  the  humerus,  through  the  shoulder-joint,  and  emerges  through 


AMPUTATIONS,  RESECTIONS,  ETC.  465 

the  anterior  part  of  the  capsule,  and  then  passes  down  the  arm,  heing 
lodged  in  the  bicipital  groove.  In  its  course  through  the  shoulder- 
joint  the  long' tendon  of  the  biceps  is  entirely  enveloped  in  a  tubular 
process  of  the  synovial  membrane,  and  thus,  although  it  passes 
through  the  shoulder- joint,  the  tendon  is  at  the  same  time  excluded 
from  it. 

Like  a  hood  or  cushion,  the  deltoid  muscle  covers  and  serves  to 
protect  the  shoulder-joint;  beneath  the  deltoid  there  is  a  bursa, 
which  sometimes  becomes  diseased. 

Below  the  acromion  and  beneath  the  deltoid  muscle  the  head  of 
the  humerus  may  be  readily  recognized.  It  may  be  felt  to  rotate 
underneath  the  soft  parts  upon  manipulation.  It  is  responsible  for 
the  rounded  contour  of  the  shoulder;  if  the  head  of  the  humerus 
leaves  the  glenoid  cavity,  the  shoulder  presents  a  peculiar  flattened 
appearance,  which  is  very  striking,  and  the  sharp  outer  end  of  the 
acromion  process  becomes  especially  prominent  and  tends  to  direct 
attention  to  the  fact  that  the  head  of  the  humerus  has  been  dis- 
located. 

ExAKTicuLATiosr  at  the  Shoulder-joint  (Spence).  -7-  The 
shoulder  should  overhang  the  edge  of  the  table  and  the  arm  should 
be  abducted  a  little  from  the  side  of  the  thorax  and  at  the  same  time 
rotated  somewhat  outward,  so  that  the  great  tuberosity  is  directed 
outward. 

The  incision  is  about  six  inches  long,  and  commences  above,  at 
the  clavicle,  between  the  acromion  and  coracoid  processes,  and  passes 
down  the  front  of  the  arm  as  far  as  the  point  where  the  deltoid  is 
attached  to  the  humerus.  This  incision  is  deep,  penetrating  through 
the  skin,  fascia,  and  muscle  down  into  the  bicipital  groove.  With 
the  long  knife  a  circular  incision  is  then  made  around  the  arm,  on 
a  level  with  the  lower  end  of  the  longitudinal  incision;  this  incision, 
upon  the  inner  aspect  of  the  arm,  should  pass  through  the  integu- 
ment and  superficial  fascia  (subcutaneous  fat)  only,  care  being  taken 
not  to  sever  the  brachial  vessels;  for  the  rest  of  the  circumference 
of  the  arm,  however,  this  circular  incision  penetrates  through  all  the 
soft  parts  to  the  bone. 

The  outer  edge  of  the  wound  is  seized,  and  with  a  scalpel  the 
soft  parts  are  dissected  away  from  the  outer  surface  of  the  humerus, 
the  arm  being  rotated  inward  by  the  assistant,  to  facilitate  this  step 
of  the  operation. 

The  capsular  ligament  being  now  exposed,  the  joint  should  be 


466 


UPPER  EXTREMITY. 


opened;  this  is  done,  not  by  passing  the  blade  of  the  knife  flatwise 
between  the  head  of  the  humerus  and  the  acromion  process,  but  by 
cutting  directly  down  upon  the  upper  surface  of  the  head  of  the  hu- 
merus, from  behind  forward,  as  though  one  would  cut  into  the  head 
of  the  bone.  During  this  step  of  the  operation  the  assistant  may  help 
by  rotating  the  arm  first  inward  and  then  outward.  In  this  way  the 
joint  is  freely  opened,  the  long  tendon  of  the  biceps  being  cut  at  the 


Fig.  1S3. — Right  Shoulder,  Anterior  View.  R,  line  of  incision  for  resec- 
tion of  shoulder-joint;  S,  incision  for  exarticulation  at  the  shoulder-joint 
(S pence). 


same  time.  The  head  of  the  bone  is  now  turned  out  of  its  socket 
and  drawn  forcibly  outward,  away  from  the  glenoid  cavity;  the  long 
knife  is  introduced  into  the  wound,  behind  the  head  of  the  humerus, 
and  the  soft  parts,  with  the  edge  of  the  knife  applied  close  to  the 
surface  of  the  bone,  are  separated  from  the  inner  aspect  of  the 
humerus  to  a  point  a  little  below  the  level  of  the  circular  incision, 
care  being  taken  not  to  injure  the  brachial  vessels,  which  run  parallel 


AMPUTATIONS,  RESECTIONS..  ETC.  467 

with  the  inner  surface  of  the  humerus,  and  which  have  not,  as  yet, 
heen  divided. 

Now,  with  a  final  stroke  of  the  knife,  the  operation  is  completed 
hy  cutting  through  the  soft  parts  upon  the  inner  aspect  of  the  arm 
down  to  the  surface  of  the  hone,  thus  severing  the  vessels  and  nerves. 
Just  hefore  this  final  cut  which  divides  the  vessels  is  made  an  as- 
sistant grasps  the  mass  of  soft  parts  which  have  been  separated  from 
the  inner  side  of  the  humerus  and  which  include  the  brachial  vessels, 
and  thus  compresses  them  while  they  are  being  cut,  and  continues 
to  hold  them  until  the  operator  can  secure  the  divided  vessels  with 
artery  forceps,  after  which  they  are  tied.  Other  vessels  which  spurt 
are  clamped  and  tied  as  the  operation  progresses. 

The  edges  of  the  skin  may  be  brought  together  with  interrupted 
catgut  sutures,  a  drain  emerging  from  the  lower  end  of  the  wound 
and  left  in  place  for  forty-eight  to  seventy- two  hours;  or  the  edges 
of  the  wound  may  be  closed  throughout  and  an  opening  made 
through  the  posterior  part  of  the  flap,  near  the  glenoid  cavity,  and 
the  wound  thus  drained.     This  latter  plan  is  very  satisfactory. 

The  above  is  a  good  method  for  exarticulation  at  the  shoulder- 
joint,  which  may  thus  be  accomplished  with  the  loss  of  but  little 
blood.  Through  the  longitudinal  incision,  which  is  first  made,  the 
joint  may  be  opened  and  freely  explored  and  drained,  or  the  joint 
may  be  excised:  this  is  a  great  advantage,  as  we  are  often  in  doubt 
as  to  the  necessity  of  exarticulation  until  after  the  joint  has  been 
opened  and  inspected. 

EXAETICTTLATIOX   AT    THE   ShOULDEE-JOINT    WITH   AN    ESAIAECH 

Bandage  Applied. — The  shoulder  overhanging  the  side  of  the  table 
and  the  arm  somewhat  abducted,  an  Esmarch  bandage  or  rubber  tube 
is  applied  tightly  about  the  axilla,  passing  around  the  shoulder  over  the 
outer  part  of  the  clavicle.  "With  a  long  knife  a  circular  incision  is 
then  made  through  the  integument  and  fat  down  to  the  deep  fascia. 
This  incision  should  be  placed  just  above  the  insertion  of  the  deltoid 
muscle.  The  integument,  which  retracts  at  once,  is  drawn  toward 
the  shoulder  by  an  assistant,  and  the  muscles,  vessels,  etc.,  divided 
by  a  second  circular  sweep  of  the  long  knife  down  to  the  bone  as 
high  up  as  the  retracted  integument  permits;  the  bone  is  then  sawn 
through  at  this  level.  The  brachial  artery  and  accompanying  veins 
are  now  clamped  and  tied;  also  the  superior  profunda,  which  is  found 
upon  the  back  side  of  the  humerus  in  company  with  the  musculo- 
spiral  nerve. 


468 


UPPER  EXTREMITY. 


After  these  vessels  have  been  tied  the  Esmarch  bandage  is  re- 
moved and  any  further  spurting  vessels  ligated. 

A  second  incision  is  now  made  from  the  acromion  process  down 
upon  the  front  of  the  stump  of  the  humerus  and  penetrating  to  the 
bone.    The  soft  parts  are  then  cut  away  from  the  outer  surface  of 


Fig.  194.— Right  Shoulder,  Posterior  View.     Outline  of  the  lateral  deltoid 
flap  for  exarticulation  at  the  shoulder-joint. 


the  stump  of  the  humerus,  tying  vessels  as  they  are  cut,  and  the 
joint  opened  by  incising  the  capsule  from  behind  forward,  including 
the  tendon  of  the  biceps;  the  head  of  the  bone  is  then  turned  out 
of  its  socket,  and  while  it  is  drawn  forcibly  outward,  away  from 
the  glenoid  cavity,  the  soft  parts  upon  its  inner  side  are  stripped 
away  from  the  bone  and  the  operation  thus  completed.     But  little 


AMPUTATIONS,  RESECTIONS,  ETC. 


469 


bloocl  is  lost.     The  wound  may  be  treated  as  in  the  preceding  oper- 
ation. 

After  the  circular  incision  has  been  made  through  the  soft  parts, 
including  the  muscles,  brachial  vessels,  etc.,  down  to  the  bone,  and 
while  the  tourniquet  is  still  applied  and  without  sawing  through  the 
bone,  one  may  ligate  the  vessels  and  then,  after  removing  the  tourni- 
quet, proceed  to  complete  the  operation  by  turning  the  head  of  the 


Fig.   195.— Left  Shoulder,   Side  View.     Outline  of  the  lateral  deltoid 
flap  for  exarticulation  at  the  shoulder-joint. 


bone  out  of  its  socket  and  stripping  the  soft  parts  away  from 
the  upper  part  of  the  bone  through  the  longitudinal  incision  as  de- 
scribed above.  This  would  save  sawing  through  the  shaft  of  the 
humerus. 

Exarticulation  at  the  Shoulder-joint  with  the  Forma- 
tion of  a  Lateral  Deltoid  Flap. — The  position  of  the  patient  is  the 
same  as  in  the  previous  operation,  the  shoulder  overhanging  the  edge 
of  the  table.    A  large  musculo-tegumentary  flap,  U-shaped  and  corre- 


470  UPPER  EXTREMITY. 

sponding  to  the  deltoid  muscle,  is  taken  from  the  outer  aspect  of 
the  arm.  The  incision  commences  anteriorly,  just  external  to  the 
coracoid  process,  and  passes  down  upon  the  front  of  the  arm  to  a 
point  a  short  distance  above  the  insertion  of  the  deltoid  muscle, 
whence  the  incision  is  carried  backward  across  the  outer  aspect  of 
the  arm  and  then  upward  as  far  as  the  spine  of  the  scapula  to  a  point 
just  posterior  to  the  acromion  process;  this  incision  reaches  to  the 
bone  throughout  its  whole  course.  In  dividing  the  muscles  the 
knife  should  be  directed  rather  obliquely,  in  order  that  the  edge  of 
the  musculo-tegumentary  flap  may  be  beveled  at  the  expense  of  the 
deeper  structures  so  that  the  muscles  will  not  protrude  beyond  the 
edges  of  the  skin,  which  retracts  considerably  when  it  is  cut.  Care 
should  be  taken  that  this  flap  is  not  tongue-shaped. 

This  outer  deltoid  flap  is  seized  with  the  fingers  and  dissected 
away  from  the  surface  of  the  bone  and  reflected  up  over  the  shoulder. 
The  spurting  branches  of  the  circumflex  artery  are  seized  with  forceps 
and  tied.  The  capsule  of  the  joint  being  now  exposed,  the  joint  may 
be  opened  by  cutting  through  the  capsule,  from  before  backward,  with 
the  edge  of  the  knife  applied  directly  against  the  upper  surface  of  the 
head  of  the  bone,  the  long  tendon  of  the  biceps  being  cut  at  the  same 
time.  The  arm  is  rotated  outward,  and  the  attachment  of  the  sub- 
scapularis  cut  from  the  lesser  trochanter;  then  rotating  inward,  the 
tendons  which  are  attached  to  the  upper  and  posterior  border  of  the 
greater  trochanter  are  divided,  when  the  head  of  the  bone  drops  away 
from  the  glenoid  cavity. 

The  joint  being  thus  widely  open,  the  upper  end  of  the  humerus 
is  dragged  outward  away  from  the  glenoid  cavity,  and  with  a  long 
knife  the  soft  parts,  attached  to  its  inner  aspect,  are  cut  away  from 
the  bone,  the  edge  of  the  knife  being  held  close  against  the  surface 
of  the  bone,  in  order  to  avoid  injuring  the  brachial  vessels,  which  run 
parallel  with  and  close  to  the  inner  surface  of  the  humerus.  After 
the  soft  parts  have  been  thus  separated  from  the  inner  aspect  of  the 
humerus  to  a  point  about  one  inch  below  the  anterior  fold  of  the  axilla, 
the  edge  of  the  knife  is  turned  inward,  and  with  a  final  stroke  a  short 
inner  flap  is  cut,  dividing  the  vessels  at  the  same  time.  Just  before 
this  final  cut,  which  divides  the  vessels,  is  made,  an  assistant  grasps 
the  mass  of  soft  parts,  which  includes  the  brachial  vessels,  and  com- 
presses them  until  the  operator  can  secure  the  ends  of  the  severed 
artery  and  accompanying  veins;  these  are  then  ligated  and  the  nerves 
drawn  down  and  cut  short. 


AMPUTATIONS,  RESECTIONS,  ETC. 


471 


Fig.  196.— Left  Arm,  Posterior  View.  E,  incision  for  resection  of  elbow- 
joint;  C,  cuneiform;  M,  os  magnum;  8,  scaphoid;  SL,  semilunar;  T,  trape- 
zium; TD,  trapezoid;   V,  unciform;  W,  incision  for  resection  of  wrist- joint. 


472  UPPER  EXTREMITY. 

The  wound  is  closed  with  interrupted  catgut  sutures,  a  drainage 
tube  which  reaches  to  the  glenoid  cavity  being  left  protruding  through 
the  posterior  part  of  the  wound. 


Fig.  197.— Resection  of  Wrist-joint.  AL,  annular  ligament  split  to  show 
the  tendons  of  extensor  secundi  (EX.S)  and  extensor  carpi  radialis  brevior 
(EX.C.R.B);  EX. I.,  tendon  of  extensor  indicis. 

Resections.  Wrist-joint. — A  tourniquet  is  applied  above  the 
elbow,  in  order  that  the  operation  may  be  bloodless.  A  dorsal  incision 
is  made,  commencing  below,  at  the  middle  of  the  ulnar  border  of  the 
metacarpal  bone  of  the  index  finger,  and  this  is  continued  upward, 


AMPUTATIONS,  RESECTIONS,  ETC.  473 

over  the  middle  of  the  posterior  surface  of  the  radius,  to  a  point  one 
inch  above  the  level  of  the  wrist-joint.  This  incision  passes  through 
the  skin  and  fat  and  runs  parallel  with  the  outer  border  of  the  extensor 
tendon  of  the  index  finger,  the  extensor  indicis. 

This  incision  is  then  gradually  deepened  step  by  step,  and  in  its 
lower  part  one  should  avoid  opening  the  sheath  of  the  extensor  in- 
dicis; in  the  upper  part  of  the  incision,  nearer  to  the  wrist-joint,  the 
tendon  of  the  extensor  carpi  radialis  brevior,  which  is  attached  to  the 
base  of  the  third  metacarpal  (that  of  middle  finger),  and  the  tendon 
of  the  extensor  secundi  are  exposed.  We  keep  to  the  inner,  ulnar, 
side  of  these  tendons,  drawing  them  toward  the  outer,  radial,  side  of 
the  wound  with  a  blunt  hook,  and  thus  avoid  cutting  them.  The 
wrist-joint  is  then  entered  by  cutting  through  its  posterior  ligament, 
between  the  tendons  of  the  extensor  indicis  and  the  extensor  secundi. 
With  blunt  retractors  the  tendons  of  the  extensor  indicis  and  ex- 
tensor eommunis  are  drawn  toward  the  ulnar  border  of  the  hand, 
and  the  tendons  of  the  extensor  secundi  and  extensor  carpi  radialis 
brevior  toward  the  radial  border.  Above  the  joint  the  incision  pene- 
trates to  the  surface  of  the  radius  between  the  bunch  of  tendons 
(extensor  communis  digitorum  and  extensor  indicis),  to  the  ulnar 
side,  and  the  extensor  secundi,  to  the  radial  side.  The  edges  of  the 
wound,  including  the  tendons,  being  well  retracted,  an  elevator  is 
introduced  and  all  the  soft  parts  separated  from  the  bones,  working 
as  close  as  possible  to  the  surface  of  the  bone.  It  may  be  necessary 
to  partially  separate  the  attachment  of  the  tendon  of  the  extensor 
carpi  radialis  brevior  from  the  base  of  the  third  metacarpal.  This 
is  accomplished  with  the  elevator  or  by  chipping  away  a  thin  sliver 
of  the  bone  with  a  chisel;  the  tendon  should  not  be  divided  with 
the  knife. 

After  the  carpal  bones  have  been  freely  exposed  the  wrist  is  flexed 
and  the  first  row  is  removed,  commencing  with  the  scaphoid,  then  the 
semilunar, — which  adjoins  it, — and  finally  the  cuneiform.  The  pisi- 
form, which  articulates  with  the  anterior  surface  of  the  cuneiform 
and  to  which  the  tendon  of  the  flexor  carpi  ulnaris  is  attached,  is 
allowed  to  remain  unless  it  is  diseased. 

With  the  wrist  still  flexed,  thus  giving  better  access  to  the  carpus, 
the  second  row  of  carpal  bones  is  now  excised,  commencing  with  the 
os  magnum,  which  is  easily  recognized  by  its  prominent  rounded  head. 
This  bone  is  seized  with  a  small  lion-tooth  forceps,  isolated,  and  re- 
moved.   Then  the  trapezoid  lying  to  the  outer  side  of  the  os  magnum 


.474  UPPER  EXTREMITY. 

and  articulating  with  the  metacarpal  bone  of  the  index  finger;  after 
this,  the  unciform  is  seized  with  the  forceps  and  removed;  the  trape- 
zium, which  articulates  with  the  metacarpal  bone  of  the  thumb,  is 
allowed  to  remain,  if  its  condition  permits,  as  its  removal  interferes 
much  with  the  function  of  the  thumb. 

It  is  not  always  necessary  to  remove  all  the  bones  of  the  carpus; 
when  diseased,  they  may  often  be  readily  enucleated  with  a  sharp 
spoon;  at  other  times  the  ligamentous  bands  which  join  the  bones  to 
each  other  and  to  the  bases  of  the  metacarpal  bones  must  be  cut  before 
they  can  be  enucleated,  and  in  doing  this  one  should  be  careful  that 
the  point  of  the  knife  does  not  wound  the  structures  in  the  palm  of 
the  hand.  There  may  be  some  difficulty  in  removing  the  scaphoid. 
In  excising  this  bone,  and  also  the  trapezium,  one  should  remember 
that  the  radial  artery  lies  in  close  proximity  to  their  posterior  surfaces. 
Although  this  vessel  is  usually  separated  from  the  bones  when  the  soft 
parts  are  detached  with  the  elevator,  and  is  therefore  not  endan- 
gered, yet  one  should  look  out  for  the  point  Of  his  knife. 

The  removal  of  the  unciform  is  rather  difficult,  owing  to  the 
irregularity  of  its  hook-like  process  and  its  muscular  attachments.  It 
may  be  seized  with  a  toothed  bone  forceps,  and,  by  twisting  it  and  at 
the  same  time  cutting  with  the  edge  of  the  knife  close  to  the  bone,  it 
may  be  removed. 

If  the  ends  of  the  radius  and  ulna  are  to  be  removed,  the  soft 
parts,  including  the  tendons,  are  separated  from  the  posterior  surface 
of  the  bones  with  the  periosteum  elevator;  the  lateral  ligaments  are 
also  detached  from  the  bones,  preferably  with  the  periosteum  elevator 
rather  than  with  the  knife,  taking  care  to  avoid  the  radial  artery  as 
it  winds  around  the  outer  side  of  the  wrist.  The  lower  ends  of  the 
bones  are  then  forced  well  out  of  the  wound  and  the  soft  parts  sepa- 
rated from  their  anterior  surfaces,  working  close  to  the  bone  or  sub- 
periosteal^, and  finally  the  ends  of  the  bones  are  sawn  off.  One 
should  avoid  the  ulnar  artery  and  nerve,  anteriorly,  toward  the  ulnar 
side.     The  tourniquet  may  now  be  removed. 

There  are  usually  no  vessels  to  tie,  none  of  importance  being 
cut.  The  hand  is  placed  upon  a  straight  anterior  splint  and  the  wound 
partly  closed  by  interrupted  sutures  and  packed  with  iodoform  gauze. 

Elbow-joint  (Langenbeck). — A  tourniquet  is  placed  about  the 
upper  part  of  the  arm.    The  operation  should  be  done  subperiosteally. 

The  arm,  with  the  elbow  flexed,  is  thrown  across  the  patient's 
chest  and  steadied  by  an  assistant;    the  operator  usually  stands  on 


AMPUTATIONS,  RESECTIONS,  ETC.  475 

same  side  as  the  diseased  joint,  although  at  times  it  is  convenient  to 
change  to  the  other  side.  An  incision,  about  four  inches  long,  is 
made  upon  the  posterior  aspect  of  the  joint.  This  incision  commences 
about  two  inches  above  the  upper  border  of  the  olecranon  process  and 
is  continued  downward  upon  the  posterior  triangular  surface  of  the 
olecranon  and  ulna,  passing,  not  through  the  middle  of  this  surface, 
but  a  little  to  the  inner  side  of  the  middle  line  and  ending  on  its 
inner  border  (see  Fig.  196).  This  incision  should  be  made  with  a 
heavy  resection  knife,  and  throughout  its  whole  length  should  pene- 
trate through  all  the  soft  parts,  including  the  periosteum,  down  to 
the  bone.  The  upper  part  of  this  incision  splits  the  tendon  of  the 
triceps  lengthwise  right  down  to  its  attachment  to  the  upper  border 
of  the  olecranon,  and  passes  through  the  posterior  ligament  of  the 
joint  to  the  surface  of  the  humerus.  The  lower  part  of  the  incision, 
corresponding  to  the  posterior  surface  of  the  olecranon,  passes  through 
the  periosteum  to  the  bone. 

Sharp  retractors  are  introduced  into  the  upper  part  of  the  wound, 
and  the  attachment  of  the  triceps  tendon  is  chiseled  away  from  the 
upper  border,  surface,  of  the  olecranon  process  on  either  side,  taking 
a  very  thin  shell  of  bone  with  it;  this  separation  may  also  be  accom- 
plished with  the  knife,  cutting  close  to  the  bone,  but  the  subcortical 
separation  with  the  chisel  is  preferable. 

The  periosteum  elevator  is  now  used  to  separate  the  soft  parts, 
including  the  periosteum,  from  the  posterior  surface  and  sides  of 
the  olecranon  process  and  the  adjoining  upper  part  of  the  ulna  and 
lower  end  of  the  humerus,  working  first  inward  toward  the  inner 
condyle  and  keeping  close  to  the  bone,  as  this  mass  of  soft  parts 
includes  the  ulnar  nerve,  which  is  lodged  in  the  groove  between  the 
inner  condyle  and  the  olecranon;  if  we  work  subperiosteally,  or  very 
close  to  the  surface  of  the  bone,  the  ulnar  nerve  is  not  seen  and  not 
endangered.  To  retract  this  mass  of  soft  parts  as  it  is  detached  from 
the  bone,  one  should  use  a  blunt-pronged  retractor.  The  separation 
of  the  soft  parts  is  continued  inward  and  around  the  inner  epicon- 
dyle.  In  separating  the  soft  parts  from  the  inner  epicondyle  one 
should  use  the  chisel  rather  than  the  knife,  since  the  tendon  com- 
mon to  the  superficial  flexor  muscles  is  attached  here,  and  it  would 
be  disadvantageous  to  cut  it.  In  a  similar  manner  the  soft  parts, 
including  the  periosteum,  are  detached  from  the  outer  side  of  the 
olecranon,  continuing  outward  until  the  external  epicond}Tle  is  de- 
nuded.   To  the  external  epicondyle  is  attached  the  tendon  common 


476  UPPEE  EXTREMITY. 

to  the  superficial  extensors,  and  therefore  one  should  avoid  using 
the  knife  here. 

The  separation  of  the  soft  parts  can  be  accomplished  almost 
entirely  with  the  elevator,  if  necessary  using  considerable  force  with 
the  sharp  edge  of  the  elevator  applied  directly  upon  the  bare  surface 
of  the  bone;  but  it  may  be  necessary  here  and  there  to  help  one's 
self  with  the  chisel  and  occasional  snips  with  the  knife.  Upon  the 
posterior  surface  of  the  olecranon  the  knife  may  be  used  a  little 
more  freely,  as  here  the  periosteum  is  thick  and  fibrous,  being  rein- 
forced by  the  triceps  tendon,  and  is  almost  impossible  to  separate 
with  the  elevator. 

After  having  denuded  the  whole  of  the  olecranon  process  and 
the  contiguous  portions  of  the  humerus,  ulna,  and  radius  out  beyond 
the  epicondyles,  the  elbow  is  flexed  and  the  lower  end  of  the  humerus 
forced  out  of  the  wound,  cutting  away  any  remaining  restricting 
bands.  The  soft  parts  about  the  anterior  aspect  of  the  lower  end 
of  the  humerus  are  then  quickly  separated  with  the  elevator  and  the 
articular  end  of  the  bone  sawn  off.  The  section  should  be  made 
through  a  plane  parallel  with  the  articular  surface.  Then,  in  a  like 
manner,  the  upper  end  of  the  radius  and  ulna  are  stripped  of  soft 
parts  and  sawn  off.  The  diseased  synovial  membrane  may  now  be 
completely  excised  with  toothed  forceps  and  blunt-pointed,  curved 
scissors.  One  should  avoid  injuring  the  structures  in  front  of  the 
joint,  brachial  artery,  etc.,  with  the  point  of  the  knife.  After  the 
resection  has  been  completed  the  tourniquet  may  be  removed.  As  a 
rule,  there  are  no  vessels  to  tie.  The  incision  is  closed,  except  for 
a  part  of  its  length,  which  is  left  open  for  drainage,  and  the  arm  put 
up  in  a  position  of  almost  complete  extension  in  a  splint  or  plaster 
of  Paris  with  a  big  wad  of  dressings. 

After  two  weeks  the  arm  may  be  gradually  or  at  once  flexed  to 
nearly  a  right  angle,  which  is  the  best  position  for  ankylosis.  Occa- 
sionally we  get  some  motion. 

Shouldek-joint  (Subpeeiosteal  Method  of  Olliek  and 
Htjetek). — The  arm  lies  at  the  side,  slightly  abducted  and  rotated 
outward,  so  that  the  greater  tuberosity  looks  outward.  An  incision  is 
made  which  commences  above,  to  the  outer  side  of  the  coracoid 
process,  and  passes  downward,  upon  the  front  of  the  arm,  for  a  dis- 
tance of  five  inches;  this  incision,  throughout  its  whole  length,  is 
carried  deep  to  the  bone  (see  Fig.  193).  When  the  edges  of  the  wound 
are  held  apart  with  blunt-pronged  retractors,  the  long  tendon  of  the 


AMPUTATIONS,  RESECTIONS,  ETC.  477 

biceps,  as  it  lies  in  the  bicipital  groove  between  the  two  tuberosities, 
is  exposed.  This  tendon  emerges  from  within  the  joint  beneath  the 
lower  border  of  the  capsule. 

This  incision  above,  to  the  outer  side  of  the  coracoid  process, 
should  extend  as  high  as  the  clavicle,  in  order  to,  allow  easy  access 
to  the  capsule  and  to  the  head  of  the  humerus. 

A  director  is  now  introduced  alongside  of  the  long  biceps  tendon, 
beneath  the  lower  border  of  the  capsule,  and  well  up  into  the  joint, 
and  upon  this  the  capsule  is  divided  as  far  upward  as  the  upper 
border  of  the  glenoid  cavity;  in  this  way  the  capsule  is  split  longi- 
tudinally throughout  its  entire  length  (the  coraco-humeral  ligament, 
which  is  a  part  of  the  capsule,  is  also  divided  in  this  cut),  and  the 
joint  is  thus  freely  opened  upon  its  anterior  aspect. 

The  tendon  of  the  biceps  is  now  lifted  out  of  its  groove  and 
drawn  outward  with  a  blunt  hook,  and  the  periosteum  incised  in  the 
upper  part  of  the  floor  of  the  bicipital  groove,  between  the  two 
tuberosities;  an  elevator,  with  a  sharp  edge,  is  then  introduced  into 
the  incision  in  the  periosteum,  and  this,  together  with  the  attach- 
ment of  the  capsule,  is  separated  from  the  inner  side  of  the  neck  of 
the  bone.  The  tendon  of  the  subscapularis  is  very  intimately  at- 
tached to  the  lesser  tuberosity,  and  in  order  to  separate  this  it  may 
be  necessary  to  use  the  knife  to  some  extent,  cutting  close  upon  the 
surface  of  the  bone,  or,  what  is  preferable,  one  may,  with  the  chisel, 
chip  off  a  thin  layer  of  the  cortex,  carrying  the  attached  tendon  with 
it. 

In  separating  the  capsule  from  its  attachment  around  the  neck 
of  the  bone  it  will  be  necessary,  here  and  there,  to  use  the  knife, 
cutting  with  its  edge  applied  close  to  the  surface  of  the  bone. 

After  the  parts  on  the  inner  aspect  of  the  bone  have  been  thus 
separated,  and  while  the  arm  is  rotated  inward  and  the  long  tendon 
of  the  biceps  hooked  over  toward  the  inner  side,  the  periosteum, 
together  with  the  attachment  of  the  capsule,  is  separated  from  the 
outer  side  of  the  bone;  this  is  accomplished  chiefly  with  the  peri- 
osteum elevator,  with  occasional  snips  with  the  knife.  The  tendons 
attached  to  the  upper  and  posterior  borders  of  the  greater  tuberosity 
are  intimately  united  with  the  bone,  and,  if  they  cannot  be  separated 
with  the  periosteum  elevator,  one  may  use  the  chisel,  as  on  the  inner 
side,  removing  a  thin  shell  of  the  cortex  along  with  the  tendon 
attachments.  During  this  part  of  the  operation  the  arm  is  rotated 
more  and  more  inward. 


4?8  UPPER  EXTREMITY. 

After  the  upper  end  of  the  hone  has  heen  thoroughly  isolated 
we  find  it  lying  in  a  sac,  formed  ahove  by  the  detached  capsule,  which 
is  continuous  below  with  the  periosteum  and  tendons  that  have  heen 
separated  from  the  hone. 

The  head  of  the  bone  is  now  thrown  out  of  this  sac  and  out  of 
the  incision,  and  may  be  sawn  off  with  the  flat  saw,  protecting  the 
neighboring  soft  parts,  or  the  chain  or  Gigli  saw  may  be  used,  or  it 
may  be  knocked  off  with  a  broad  chisel. 

After  the  head  of  the  bone  has  been  removed,  the  interior  of 
the  joint  becomes  accessible,  and  one  may  dissect  away  all  the  syn- 
ovial membrane  lining  the  joint  with  toothed  forceps  and  strong, 
blunt-pointed  scissors,  curved  on  the  flat. 

The  glenoid  surface  of  the  scapula,  if  diseased,  may  be  thor- 
oughly curetted  with  the  sharp  spoon,  or  chiseled  or  gouged  out  with 
the  rongeur  bone  forceps.  Usually  no  vessels  of  importance  are  cut; 
any  spurting  points  may  be  caught  and  tied  as  the  operation  pro- 
gresses. 

The  cavity  of  the  joint  should  be  freely  drained  through  the 
lower  part  of  the  incision,  using  a  good-sized  tube.  An  additional 
opening  may  be  made  posteriorly  to  provide  still  better  drainage. 
This  opening  is  made  by  pushing  an  artery  forceps  through  the  mass 
of  deltoid  muscle  from  within  and  then  incising  the  skin  with  the 
knife  upon  this.  We  avoid  making  the  opening  through  the  deltoid 
with  the  knife  in  order  not  to  wound  the  circumflex  nerve  and  ves- 
sels. The  opening  through  the  muscle  may  be  made  as  large  as 
desired  by  spreading  the  blades  of  the  forceps.  In  closing  the  incis- 
ion interrupted  silk-worm  gut  sutures,  which  pass  through  all  the 
structures,  including  the  edges  of  the  split  capsule,  should  be  em- 
ployed. 

If  it  is  intended  to  remove  the  head  of  the  bone  only,  it  is  not 
necessary  to  separate  the  periosteum  for  more  than  a  short  distance 
upon  the  shaft.  Usually  separation  of  the  capsule  around  the  an- 
atomical neck  and  the  tendons  partially  from  the  greater  and  lesser 
tuberosities  will  give  sufficient  room  to  permit  of  the  excision  of  the 
head  of  the  bone.  Only  when  the  head  of  the  bone  is  to  be  excised 
below  the  trochanters  is  it  necessary  to  separate  the  periosteum  and 
tendons  for  a  greater  distance  below  the  anatomical  neck. 

The  operation  as  described  above  differs  from  Langenbeck's  only 
as  regards  the  incision.  The  incision  of  Langenbeck  commences 
above  at  the  acromion  process,  and  is  therefore  more  external;  pass- 


AMPUTATIONS,  RESECTIONS,  ETC.  479 

ing  through  the  body  of  the  deltoid,  it  divides  the  circumflex  nerve, 
and  is  therefore  likely  to  be  followed  by  impairment  of  the  function 
of  the  deltoid. 

Tendon  Suture. — Tendons  may  be  found  divided  as  a  complication 
of  a  wound,  or  they  may  be  accidentally  cut  by  the  surgeon  during  the 
course  of  an  operation  about  a  joint;  one  or  several  may  be  severed. 
The  proximal  portion  of  the  tendon,  that  which  is  joined  to  the  muscle, 
may  be  separated  a  considerable  distance  from  the  distal  portion,  owing 
to  the  contraction  of  the  muscle,  and  at  times  considerable  search  may 
be  necessary  to  secure  it,  or  it  may  be  necessary  to  lay  the  sheath  of  the 
tendon  open  for  this  purpose. 

The  ends  should  be  approximated  and  joined  by  a  catgut  suture, 


Fig.  198.— Divided  Tendon  Reunited  by  a  Single  Mattress  Suture. 

one  passing  through  the  tendon  proper  being  probably  the  most  satis- 
factory. If  the  flexor  tendons  are  divided,  in  order  to  coapt  the  ends 
and  retain  them  in  position  with  the  minimum  degree  of  tension,  the 
joint  must  be  placed  in  a  position  of  flexion,  and  the  reverse  when  the 
extensor  tendons  are  severed.  Asepsis  is  a  necessary  condition  to 
healing;  if  the  parts  are  infected,  an  effort  should  be  made  to  render 
them  sterile,  and  under  these  circumstances  drainage  in  addition  is 
probably  advisable. 

Nerve  Suture. — A  nerve-trunk  may  be  severed,  either  accidentally 
by  the  surgeon  during  the  course  of  an  operation  or  the  condition  may 
be  encountered  as  a  complication  of  an  accidental  wound. 

The  ends  should  be  approximated  and  united  with  one  or  more 


480 


UPPER  EXTREMITY. 


plain  catgut  sutures,  which  may  be  passed  through  the  body  of  the 
nerve  proper.  The  union  may  be  effected  immediately  after  the  oc- 
currence of  the  accident  or  after  the  lapse  of  considerable  time.  If 
immediate,  it  is  simply  necessary  to  coapt  the  ends  and  retain  them 
in  position  with  one  or  two  sutures;  if  after  the  lapse  of  a  considerable 
period,  it  will  be  necessary  to  search  for  the  ends  of  the  divided  nerve, 
and,  after  they  are  found,  freshen  them,  before  uniting  them,  end  to 
end,  by  suture.     Plain  catgut  is  preferable  for  the  suture  material. 

Intravenous  Saline  Infusion.  —  Any  prominent  superficial  vein 
may  be  used  for  this  purpose;  the  median  cephalic  at  the  bend  of  the 
elbow  is  the  one  usually  selected.  A  tourniquet  is  first  applied  about 
the  arm,  high  up  near  the  axilla  and  just  sufficiently  tight  to  constrict 
the  superficial  veins,  but  not  tight  enough  to  shut  off  the  arterial  cur- 
rent; this  causes  the  superficial  veins  to  become  swollen  and  more  con- 


Fig.  199. — Superficial  Vein  Exposed  for  Saline  Infusion.  The  vein,  which 
is  raised  upon  the  director,  has  been  opened  ready  to  introduce  the  cannula. 
Suture  (A)  has  been  tied.  Suture  (B)  surrounds  the  vein,  but  has  not  been 
tied;  one  loop  of  the  knot  has  been  taken,  but  not  drawn  tight. 

spicuous.  The  skin  is  then  pinched  up  over  the  vein  and  may  be  in- 
cised by  transfixion  with  the  knife  or  with  the  scissors,  care  being  taken 
not  to  injure  the  vein  itself.  The  vein  is  then  thoroughly  isolated  for 
about  one  inch  and  raised  well  out  of  its  bed  upon  a  director,  after 
which  a  double  catgut  ligature  is  passed  around  the  vein.  This  liga- 
ture is  then  cut,  so  as  to  leave  the  vein  surrounded  by  two  ligatures, 
one  above  and  the  other  below.  A  single  loop  of  a  knot  is  taken  loosely 
in  the  upper  ligature,  the  ends  of  which  are  left  long.  The  vein  is  now 
freely  opened  with  a  narrow-bladed  knife  and  the  lower  ligature  then 
tied  tight  around  the  vein.  Through  the  opening  made  in  the  vein  the 
end  of  the  cannula  is  slipped  up  into  the  vein  beyond  the  upper  liga- 
ture, which  is  then  tied  fast  about  the  cannula,  in  order  to  retain  it 
securely  in  place  within  the  vein. 

Care  should  be  taken  to  introduce  the  cannula  into  the  lumen 
of  the  vein,  and  not  into  the  loose  connective  tissue  that  surrounds 


AMPUTATIONS,  RESECTIONS,  ETC.  481 

the  vein.  This  is  an  accident  which  may  readily  occur,  and  is  to  be 
avoided  by  thoroughly  isolating  the  vein  and  lifting  it  well  out  of  its 
bed  before  incising  it.  Before  the  cannula  is  introduced  into  the  vein 
the  solution  should  be  allowed  to  flow  in  order  to  fill  the  cannula  and 
thus  avoid  carrying  air  into  the  vein;  although  it  is  of  no  consequence 
if  a  small  quantity  of  air  does  enter  the  vein,  nevertheless  this  should 
be  avoided  if  possible. 

After  the  ligature  has  been  tied  and  the  cannula  thus  secured  in 
the  vein,  the  tourniquet  is  removed  from  the  arm  and  the  fluid  allowed 
to  flow;  from  1  to  2  quarts  at  a  temperature  of  about  115°  F.  may  be 
introduced.1  The  reservoir  should  be  held  at  an  elevation  of  two 
feet. 


1  A  degree  of  heat  that  the  hand  can  conveniently  endure  if  no  thermometer  is 
at  hand. 


81 


PART  X. 

THE  LOWER  EXTREMITY. 


THE  THIGH. 

The  muscles  and  other  structures  of  the  thigh  are  enveloped  by 
the  skin  and  the  superficial  fascia,  which  is  areolar  in  structure  and  in- 
cludes the  subcutaneous  fat.  These  layers  are  loose,  and  movable  upon 
the  deeper  parts.  Beneath  the  fat  (superficial  fascia)  there  is  a 
strong,  tense,  fibrous  envelope,  thicker  in  some  parts  than  in  others, 
— the  proper,  or  deep,  fascia, — which,  in  the  region  of  the  thigh,  is 
called  the  fascia  lata.  This  layer  is  attached  above  to  Poupart's 
ligament,  the  crest  of  the  pubis,  sacrum,  and  rami  of  the  pubis,  and 
below — about  the  knee-joint,  to  all  the  prominent  bony  points;  it 
confines  the  muscles  and  furnishes  septa,  which  pass  in  between  the 
different  groups  of  muscles  to  be  attached  to  the  ridges  on  the  femur. 
Beneath  the  skin,  in  the  fatty  layer,  ramify  the  various  subcutaneous 
veins  and  nerves,  and  in  the  region  of  the  groin  the  subcutaneous 
arterial  branches  that  are  derived  from  the  femoral. 

The  Gluteal  Region.  —  The  gluteal  region  corresponds  to  the 
upper  back  part  of  the  thigh,  and  presents  the  prominence  of  the  but- 
tock. This  is  more  developed  in  some  persons  than  in  others,  espe- 
cially in  females,  and  is  due  chiefly  to  the  cushion  of  fat  beneath  the 
skin. 

After  the  skin  and  fat  have  been  reflected,  the  deep  fascia,  fascia 
lata,  is  exposed.  This  fascia  is  rather  thin  in  this  region,  and  through 
it  the  fasciculi  of  the  gluteus  maximus  muscle  may  be  recognized. 
The  fascia  lata  is  attached  above  to  the  crest  of  the  ilium;  below  it 
is  continuous  with  the  same  layer  of  fascia  upon  the  back  of  the  thigh; 
internally  it  is  attached  to  the  sacrum  and  coccyx. 

The  gluteus  maximus  is  a  broad,  thick  muscle;  it  arises  from  the 
upper,  posterior  portion  of  the  external  surface  of  the  ilium,  from  the 
side  of  the  sacrum  and  coccyx,  from  the  lumbo-sacral  aponeurosis, 
and  from  the  great  sacro-aciatic  ligament.  In  coarse  bundles  its 
fibers  pass  downward  and  outward;  the  upper  fibers  become  tendons, 
and  pass  across  the  great  trochanter  and  are  inserted  into  the  fascia 
lata  upon  the  outer  aspect  of  the  thigh;  the  lower  fibers  are  attached 
(482) 


THIGH.  483 

to  the  femur  along  the  line  which  passes  from  the  great  trochanter 
downward  to  the  linea  aspera. 

The  muscle  should  be  cut  through  at  right  angles  to  the  course 
of  its  fibers  and  reflected,  when  the  bursEe  beneath  it,  one  corre- 
sponding to  the  trochanter  major  and  the  other  to  the  tuber  ischii, 
may  be  examined  and  the  parts  which  lie  beneath  the  muscle  exposed 
to  view.  Above  and  in  front  is  the  posterior  portion  of  the  gluteus 
medius,  and  below  this,  but  upon  the  same  plane,  the  pyriformis; 
these  two  muscles  are  separated  from  each  other  by  a  cellular  interval, 
through  which  the  gluteal  vessels  and  nerves  are  seen  to  emerge  from 
within  the  pelvis.  Below  the  pyriformis,  but  still  upon  the  same 
plane,  are  the  two  gemelli  and  the  tendon  of  the  obturator  internus. 
Still  lower  is  found  the  quadratus  femoris,  which  is  really  the  upper 
part  of  the  adductor  magnus  muscle.  These  muscles  are  all  attached 
to  the  femur  at  or  near  the  great  trochanter.  Passing  downward  from 
the  tuberosity  of  the  ischium  are  the  semimembranosus  and  the  semi- 
tendinosus  and  biceps  muscles. 

The  space  which  exists  in  the  skeleton  between  the  lateral  border 
of  the  sacrum  and  coccyx  and  the  margin  of  the  ischium  is  converted 
into  two  foramina,  the  greater  and  lesser  sacro-sciatic  foramina,  by 
the  greater  and  lesser  sacro-sciatic  ligaments.  The  greater  sacro-sciatic 
ligament  is  attached  by  its  broad  base  to  the  margin  of  the  sacrum  and 
coccyx  and  by  its  other  end  to  the  tuberosity  of  the  ischium;  the  poste- 
rior surface  of  the  great  sacro-sciatic  ligament  gives  attachment  to 
some  fibers  of  the  gluteus  maximus  muscle.  The  lesser  sacro-sciatic 
ligament  is  attached  to  the  margin  of  the  sacrum  and  coccyx  and  to 
the  spine  of  the  ischium;  the  lesser  is  situated  upon  a  plane  anterior 
to  the  greater. 

Through  the  greater  sacro-sciatic  foramen  emerge  the  pyriformis 
muscle;  the  gluteal  vessels  and  nerve  which  appear  above  the  pyri- 
formis, between  it  and  the  gluteus  medius;  the  sciatic  artery  and  great 
sciatic  nerve,  which  appear  below  the  pyriformis,  and  the  internal 
pudic  vessels  and  nerve.  The  internal  pudic  vessels  and  nerve,  after 
emerging  from  the  pelvis  through  the  great  sacro-sciatic  foramen, 
curve  around  the  lesser  sacro-sciatic  ligament,  close  to  the  ischium, 
and  pass  forward  into  the  deep  part  of  the  perineum. 

Stretching  the  Sciatic  Xerve. — The  patient  lies  upon  the  ab- 
domen with  a  sand  bag  under  the  lower  part  of  the  trunk.  An  incision 
three  inches  long  is  made  upon  the  back  of  the  thigh,  the  upper  end 
of  the  incision  corresponding  to  the  middle  of  a  line  drawn  from  the 


484 


LOWER  EXTREMITY. 


tuberosity  of  the  ischium  to  a  point  a  hand's  breadth  below  the 
great  trochanter;  this  incision  passes  through  the  skin  and  fat 
down  to  the  deep  fascia;  the  lower  edge  of  the  gluteus  maximus 
is  now  recognized,  and  at  this  point  the  deep  fascia,  fascia  lata, 
is  incised;  through  the  opening  thus  made  in  the  deep  fascia  two 
fingers  are  introduced  and  passed  under  the  edge  of  the  gluteus 


Fig.  200.— Stretching  Sciatic  Nerve.     B,  tendon  of  biceps;  OM,  lower  edge 
of  gluteus  maximus;  N,  sciatic  nerve. 


maximus,  and  the  sciatic  nerve  hooked  up  and  drawn  out  of  the 
wound.  Three  or  four  fingers  being  now  passed  under  the  nerve, 
it  may  be  stretched  to  the  desired  degree,  pulling  with  a  gradually 
increasing  force  up  to  one  hundred  pounds;  this  may  be  repeated 
once  or  twice;  in  order  to  regulate  the  force  one  may  use  a  scale 
and  hook.    No  vessels  are  met  with,  and  it  will  but  rarely  be  neces- 


THIGH.  485 

sary  to  apply  any  ligatures;  the  wound  in  the  skin  is  closed  without 
drainage. 

The  Anterior  Femoral  Region.  —  Upon  the  anterior  part  of  the 
thigh  just  below  the  inner  end  of  Poupart's  ligament  is  the  saphenous 
opening;  this  is  a  slit-like  opening  in  the  deep  fascia,  fascia  lata, 
through  which  the  internal  saphenous  vein  passes  to  join  the  femoral. 
Its  outer  margin  presents  a  prominent,  curved,  overhanging  edge, 
the  falciform  process.  The  femoral  vessels  are  situated  beneath  the 
iliac  portion  of  the  fascia  lata,  external  and  adjacent  to  this  falciform 
margin,  resting  upon  the  pectineus  and  ilio-psoas  muscles  (see 
Femoral  Region,  Hernia). 

This  falciform  process,  or  margin,  is  continuous  above  with 
Poupart's  ligament,  and  may  be  traced  farther  inward  into  Gimber- 
nat's  ligament;  below  it  curves  inward  and  upward  beneath  the 
saphenous  vein,  and  is  here  continuous  with  that  portion  of  the 
fascia  lata,  pubic  portion,  which  covers  the  surface  of  the  pectineus 
muscle,  being  continued  upward  upon  the  surface  of  this  muscle  and 
under  Poupart's  ligament  as  far  as  the  pectineal  line,  where  it  is 
attached  (see  Figs.  148  and  154).  In  the  upper  part  of  the  thigh, 
behind  the  femoral  vessels,  this  fascia  that  covers  the  pectineus  mus- 
cle is  continuous  with  that  which  covers  the  ilio-psoas  muscle,  the 
fascia  iliaca. 

The  saphenous  opening  is  partly  closed  by  a  wad  of  fascia,  Avhich 
is  adherent  around  the  margin  of  the  opening  and  which  is  called 
the  fascia  cribrosa.  The  fascia  cribrosa  is  pierced  by  the  internal 
saphenous  vein,  which  passes  through  the  saphenous  opening  and 
joins  the  femoral  vein  on  its  inner  side. 

The  Inteknal  Saphenous  Vein  lies  beneath  the  fatty  layer  of 
the  skin;  it  commences  upon  the  dorsum  of  the  foot,  and  passes  up- 
ward in  front  of  the  internal  malleolus,  along  the  inner  side  of  the  leg, 
and  across  the  knee-joint  behind  the  internal  condyle,  immediately 
above  which  it  often  presents  a  pouch-like  dilatation;  it  is  continued 
upward  upon  the  inner,  front  aspect  of  the  thigh,  and  just  below 
Poupart's  ligament  passes  through  the  saphenous  opening  to  join 
the  femoral.  It  receives  many  branches  all  along  its  course.  That 
part  of  the  vein  and  its  tributaries  which  correspond  to  the  leg  and 
to  the  neighborhood  of  the  knee-joint  are  apt  to  become  very  tortu- 
ous, dilated,  and  pouched,  exhibiting  the  common  condition  known  as 
"varicose  veins."  Just  before  it  enters  the  saphenous  opening  the 
vein  receives  many  branches  from  the  front  and  inner  side  of  the 


486  LOWER  EXTREMITY. 

thigh,  all  radiating  toward  the  saphenous  opening,  and  here  also  it 
receives  the  veins  which  correspond  to  the  subcutaneous  branches 
of  the  femoral  artery.  The  saphenous  vein  is  accompanied  by  a 
chain  of  lymphatics  which  terminate  in  nodes  located  about  the 
saphenous  opening,  and  these  may  become  enlarged  and  tender  when 
infectious  processes  are  present  below  in  the  integument  of  the  leg 
or  thigh. 

Those  lymphatics  which  are  situated  along  Poupart's  ligament 
in  the  groin  are  usually  enlarged  when  the  external  genitals  are  the 
seat  of  disease. 

In  this  anterior  femoral  region  also,  lying  beneath  the  skin,  are 
found  the  superficial  branches  from  the  femoral  artery.  The  super- 
ficial epigastric  passes  through  the  saphenous  opening  and  upward 
across  Poupart's  ligament  to  ramify  upon  the  lower  abdomen.  The 
superficial  external  pudic  passes  through  the  saphenous  opening  and 
inward  to  supply  the  skin,  etc.,  of  the  external  genitals.  The  super- 
ficial circumflex-iliac  passes  upward  and  outward,  piercing  the  deep 
fascia  external  to  the  saphenous  opening  and  runs  parallel  with,  and 
below  Poupart's  ligament,  supplying  the  skin  and  glands  in  this 
region. 

These  vessels  are  usually  cut  in  making  the  incision  for  hernia 
and  in  extirpating  diseased  glands  in  this  region. 

The  Femoral  Artery.  Scarpa's  Triangle. — Upon  removing  the 
integument  and  deep  fascia  from  the  upper  anterior  part  of  the  thigh 
we  expose  a  triangular  space,  Scarpa's  triangle.  This  triangle  corre- 
sponds to  the  upper  third  of  the  thigh;  its  base,  which  is  above,  is 
formed  by  Poupart's  ligament;  its  outer  border  by  the  sartorius 
muscle,  and  its  inner  border  by  the  adductor  longus.  The  apex  of 
the  triangle  is  below  where  these  muscles  meet.  The  floor  of  the 
triangle  is  formed,  from  within  outward,  by  the  adductor  longus,  the 
pectineus,  and  the  ilio-psoas. 

Passing  downward  through  this  space,  from  the  middle  of  its 
base — i.e.,  midway  between  the  anterior  superior  spine  of  the  ilium 
and  the  spine  of  the  pubic  bone — to  its  apex,  is  the  femoral  artery 
accompanied  by  the  femoral  vein.  The  femoral  artery  is  the  con- 
tinuation downward  into  the  thigh  of  the  external  iliac,  and  emerges 
from  the  abdomen  underneath  Poupart's  ligament  at  the  point  al- 
ready described.  Toward  the  lower  part  of  Scarpa's  triangle  the 
femoral  artery  is  overlapped  by  the  inner  edge  of  the  sartorius 
muscle. 


THIGH. 


487 


After  traversing  Scarpa's  triangle  the  femoral  vessels  are  con- 
tinued downward  along  the  inner  side  of  the  thigh,  lying  beneath 
the  sartorius  muscle,  quite  close  to  the  femur,  within  Hunter's 
canal. 

Hunter's  Canal  is  a  musculo-fibrous  space  corresponding  to  the 
middle  third  of  the  thigh,  lying  close  to  the  inner  side  of  the  femur; 
its  outer  wall  is  formed  by  the  vastus  internus,  which  separates  the 
vessels  from  the  bone;    its  inner  wall  by  the  adductor  longus,  and 


Fig.  201.— Section  through  the  Middle  of  the  Left  Thigh. 


in  the  lower  part  of  the  thigh  by  the  adductor  magnus;  the  space 
between  the  muscles  is  roofed  over  by  a  fibrous  sheet,  which  is  de- 
rived from  the  deep  fascia.  Hunter's  canal  ends  below,  above  the 
internal  condyle,  at  the  foramen  in  the  adductor  magnus  muscle, 
through  which  the  femoral  vessels  pass  into  the  popliteal  space. 

About  two  inches  below  Poupart's  ligament  the  femoral  artery 
gives  off  a  large  branch,  the  profunda  femoris.  This  vessel  arises 
from  the  outer  and  posterior  aspect  of  the  femoral  artery;  at  its 
origin  it  curves  slightly  outward  and  then  passes  behind  the  femoral 
artery  and  vein,  and  dips  into  the  floor  of  Scarpa's  triangle,  passing 


488  LOWER  EXTREMITY. 

through  the  space  between  the  adductor  longus  and  the  pectineus; 
it  then  descends  in  the  thigh,  resting  upon  the  adductor  magnus 
along  the  inner  side  of  the  femur  and  giving  off  branches  which 
perforate  the  adductor  magnus  to  anastomose  with  branches  upon 
the  back  of  that  muscle. 

The  femoral  artery  gives  off  other  small  branches  in  Scarpa's 
triangle,  but  they  are  of  little  surgical  importance. 

As  the  femoral  artery  emerges  from  underneath  Poupart's  liga- 
ment it  is  accompanied  by  the  femoral  vein,  which  lies  to  its  inner 
side.  During  the  course  of  the  artery  through  Scarpa's  triangle 
the  vein  gradually  gets  to  lie  behind  the  artery,  and  in  Hunter's 
canal  it  is  located  behind  and  a  little  to  its  outer  side. 

As  the  femoral  vessels  pass  out  through  the  femoral  space,  be- 
neath Poupart's  ligament,  they  are  inclosed  in  a  connective  tissue 
sheath,  which  is  continuous  with  the  subperitoneal  connective  tissue 
of  the  abdomen  and  which  is  closely  adherent  all  around  the  margin 
of  the  femoral  space:  above  to  Poupart's  ligament,  below  to  the 
fascia  which  covers  the  ilio-psoas  and  pectineus  muscles,  and  inter- 
nally to  the  margin  of  Gimbernat's  ligament.  This  femoral  sheath 
is  divided  into  three  distinct  compartments  by  fibrous  septa;  the 
outer  compartment  contains  the  artery,  the  middle  one  the  vein; 
the  inner  compartment  contains  a  small  amount  of  connective  tissue 
and  fat,  and  through  it  the  lymphatics  from  the  thigh  pass  into  the 
abdomen.  This  inner  compartment  is  continued  but  a  short  dis- 
tance downward  upon  the  inner  side  of  the  femoral  vein;  it  corre- 
sponds to  the  space  between  the  femoral  vein  and  the  outer  edge 
of  Gimbernat's  ligament,  and  forms  the  crural  canal,  into  which  the 
gut  descends  in  femoral  hernia. 

As  the  vessels  emerge  from  the  abdomen  under  Poupart's  liga- 
ment they  are  contained  within  their  sheath,  which  is,  in  turn,  par- 
tially covered  anteriorly  by  that  portion  of  the  fascia  lata  which  lies 
external  to  the  falciform  edge  of  the  saphenous  opening;  underneath 
Poupart's  ligament  the  vessels  within  their  sheath  rest  upon  the  ilio- 
psoas and  pectineus  muscles. 

The  ilio-psoas  muscle  is  covered  over  by  a  layer  of  fascia,  the 
iliac,  which  is  continuous  internally  with  the  fascia  that  covers  the 
pectineus  muscle  (the  pubic  portion  of  the  fascia  lata).  This  layer 
of  fascia,  which  covers  the  ilio-psoas  muscle,  is  simply  the  continua- 
tion downward,  under  Poupart's  ligament  into  the  thigh,  of  the 
fascia  iliaca,  which  covers  these  muscles  within  the  abdomen. 


THIGH.  489 

The  Anterior  Crural  Nerve. — At  Poupart's  ligament,  lying  to 
the  outer  side  of  the  femoral  artery  and  imbedded  in  the  substance  of 
the  ilio-psoas  muscle,  is  the  anterior  crural  nerve.  This  nerve  is 
separated  from  the  femoral  artery  by  the  iliac  fascia,  which  invests 
the  ilio-psoas  muscle  and  is  not  seen  in  the  thigh  until  this  layer 
of  fascia  has  been  incised. 

Below  Poupart's  ligament  the  anterior  crural  nerve  divides  into 
cutaneous  and  muscular  branches.  The  internal  or  long  saphenous 
nerve,  the  largest  of  the  cutaneous  branches,  approaches  the  femoral 
artery  as  it  lies  in  Scarpa's  triangle,  and  accompanies  it  down  along 
the  inner  side  of  the  thigh,  through  Hunter's  canal.  At  the  lower 
end  of  the  canal,  where  the  femoral  vessels  pass  through  the  ad- 
ductor foramen  into  the  popliteal  space  and  just  above  the  internal 
condyle,  the  nerve  becomes  more  superficial,  lying  beneath  the 
sartorius;  below  the  knee-joint  it  becomes  subcutaneous,  and  runs 
down  the  inner  side  of  the  leg  in  company  with  the  internal  saphe- 
nous vein,  and  supplies  the  skin  of  the  leg. 

Ligation  of  the  Femoral  Artery.  The  Common  Femoral. — ■ 
The  common  femoral  is  sometimes  ligated  as  a  preliminary  to  exartic- 
ulation  of  the  thigh  at  the  hip- joint.  The  vessel  is  ligated  immediately 
below  Poupart's  ligament,  above  the  origin  of  the  profunda  femoris 
branch,  where  it  is  quite  superficial. 

An  incision  about  two  inches  long  is  made,  commencing  above, 
at  the  middle  of  Poupart's  ligament;  i.e.,  at  a  point  midway  between 
the  anterior  superior  iliac  spine  and  the  spine  of  the  pubes.  This 
incision  passes  through  the  skin  and  fat  down  to  the  deep  fascia,  the 
fascia  lata.  The  pulsation  of  the  artery  may  be  readily  felt  with 
the  finger  in  the  wound. 

The  deep  fascia  is  incised  and  the  artery  exposed  by  stripping 
away  its  connective  tissue  sheath.  An  aneurism  needle,  carrying  a 
catgut  ligature,  is  passed  around  the  vessel  from  within  outward, — 
i.e.,  between  the  vein  and  artery, — and  then  withdrawn,  thus  leaving 
the  artery  surrounded  by  the  ligature,  which  is  tied.  The  femoral 
vein,  which  lies  to  the  inner  side  of  the  artery,  may  be  tied  at  the 
same  time,  through  the  same  incision.  The  wound  is  closed  with 
several  interrupted  sutures.  This  procedure  makes  the  exarticula- 
tion  at  the  hip-joint  practically  a  bloodless  operation. 

The  Femoral  in  Scarpa's  Triangle. — The  femoral  artery  is 
occasionally  ligated  for  aneurism  involving  its  lower  portion  or  its 
continuation,  the  popliteal. 


490 


LOWER  EXTREMITY. 


For  this  purpose  the  ligature  is  usually  applied  in  the  lower 
part  of  Scarpa's  triangle,  about  five  inches  below  Poupart's  ligament, 
and  therefore  below  the  origin  of  its  profunda  femoris  branch.    The 


/     X, 


Fig. 


202. — Ligation  of  Femoral  Artery.     OF,  incision  lor  ligation  of  common 
femoral;  F,  incision  for    ligation  of  femoral  in  Scarpa's  triangle. 


course  of  the  artery  is  indicated  by  a  line  drawn  from  a  point  above, 
midway  between  the  anterior  superior  spine  of  the  ilium  and  the 
spine  of  the  pubes,  to  the  internal  condyle  below.     The  muscular 


THIGH.  491 

guide  to  the  artery,  in  this  part  of  its  course,  is  the  inner  border  of 
the  sartorius  muscle,  which  slightly  overlaps  the  vessel. 

The  patient  is  placed  upon  the  back,  with  the  leg  rotated  slightly 
outward.  The  incision  is  made  about  three  inches  long,  correspond- 
ing to  the  inner  border  of  the  sartorius  muscle;  it  commences  above, 
about  four  inches  below  Poupart's  ligament.  This  incision  passes 
through  the  skin  and  subcutaneous  fat  and  through  the  sheath  of 
the  sartorius,  exposing  the  inner  edge  of  this  muscle;  the  muscle  is 
readily  recognized  by  the  oblique  course  of  its  fibers.  In  this  in- 
cision some  tributaries  of  the  long  saphenous  vein  are  cut  and 
•clamped.  Having  fully  recognized  the  edge  of  the  sartorius  muscle, 
this  is  drawn  outward,  and  the  vessel  may  then  be  located  by  its 
pulsation  beneath  the  deep  fascia;  this  layer  of  deep  fascia  is  incised 
along  the  course  of  the  artery  and  the  vessel  thus  exposed.  In  this 
situation  the  vein  is  found  lying  behind  the  artery  and  still  slightly 
to  its  inner  side;  the  long  saphenous  nerve  lies  a  short  distance  to 
the  outer  side  of  the  artery.  "We  may  see  the  internal  cutaneous 
nerve  passing  obliquely  inward  across  the  sheath  of  the  artery. 

The  loose  connective  tissue,  which  forms  the  sheath  of  the 
.artery,  is  now  picked  up  with  a  thumb  forceps  and  nicked  with  the 
point  of  the  knife,  and  through  the  opening  thus  made  a  director  is 
introduced  between  the  artery  and  the  vein,  working  around  the 
.artery,  close  to  its  wall,  from  within  outward.  After  the  artery  has 
been  thus  isolated  a  catgut  ligature  is  carried  around  it,  also  from 
within  outward,  in  an  aneurism  needle.  Before  tying  the  ligature 
•one  should  again  investigate  to  make  certain  that  the  artery  alone 
is  included,  and  then  tie  a  single  square  knot.  The  incision  is  closed 
with  several  catgut  sutures. 

The  Popliteal  Space. — The  femoral  artery  and  vein,  having  passed 
through  the  opening  in  the  lower  part  of  the  adductor  magnus  muscle, 
enter  the  popliteal  space,  and  are  known  here  as  the  popliteal  artery 
•and  vein. 

The  popliteal  space  is  lozenge-shaped  and  situated  behind  the 
knee.  It  is  bounded  above  and  externally  by  the  biceps;  above  and 
internally  by  the  semimembranosus,  semitendinosus,  gracilis,  and 
•sartorius,  the  tendons  of  these  muscles  being  known  as  the  outer  and 
inner  hamstrings,  respectively.  Below  and  externally  the  space  is 
bounded  by  the  outer  head  of  the  gastrocnemius,  and  below  and  in- 
iernally  by  the  inner  head  of  the  same  muscle.  The  floor  of  the 
•.space  is  formed,  from  above  downward,  by  the  posterior  surface  of 


492  LOWER  EXTREMITY. 

the  lower  end  of  the  femur,  the  posterior  ligament  of  the  knee-joint, 
and  the  popliteus  muscle. 

Passing  from  the  upper  angle,  through  the  space,  to  the  lower- 
angle,  where  it  becomes  the  posterior  tibial,  is  the  internal  popliteal 
nerve.  In  the  upjDer  part  of  the  space,  emerging  from  beneath  the 
biceps  muscle,  is  the  external  popliteal  nerve;  this  nerve  passes  down- 
ward and  outward  along  the  inner  edge  of  the  biceps  tendon. 

The  popliteal  artery,  with  its  accompanying  vein,  enters  the  pop- 
liteal space  above,  emerging  from  beneath  the  semimembranosus,  near 
the  upper  angle  of  the  space;  therefore  in  the  upper  part  of  the  space 
the  artery  lies  to  the  inner  side  of  the  internal  popliteal  nerve;  about 
the  middle  of  the  space,  however,  the  artery  passes  underneath  the 
nerve;  and  in  the  lower  part  of  the  space  it  is  found  to  the  outer  side 
of  the  nerve. 

The  popliteal  artery  lies  close  to  the  floor  of  the  popliteal  space, 
separated  from  the  posterior  ligament  of  the  knee-joint  by  a  little- 
connective  tissue;  the  vein  is  placed  superficial  to  the  artery  and 
rather  to  its  outer  side;  the  internal  popliteal  nerve  lies  superficial 
to  the  vessels,  crossing  them  from  above  downward.  The  popliteal 
artery  gives  off  several  branches,  but  they  are  of  no  surgical  impor- 
tance. 

The  popliteal  space  is  covered  by  the  skin  and  superficial  fascia, 
(fat)  and  by  the  deep  fascia,  which  is  stretched  between  the  ham- 
string tendons.  When  the  popliteal  artery  reaches  the  lower  part 
of  the  popliteal  space  it  divides  into  two  branches,  the  anterior  and 
posterior  tibial. 

It  is  seldom  or  never  necessary  to  tie  the  popliteal;  for  popliteal 
aneurism  the  ligation  of  the  femoral  is  preferred. 

THE  LEG. 

The  Anterior  Tibial  Artery. — Just  below  the  lower  border  of  the 
popliteus  muscle  the  anterior  tibial  artery  passes  forward,  through 
an  opening  in  the  interosseous  membrane  between  the  tibia  and  the 
fibula,  to  the  front  of  the  leg;  it  then  passes  downward,  lying  upon 
the  front  surface  of  the  interosseous  membrane,  accompanied  by  two 
vena?  comites,  one  on  either  side.  In  the  upper  third  of  the  leg  the 
vessel  lies  between  the  tibialis  anticus  on  its  inner  side  and  the- 
extensor  longus  pollicis  on  its  outer  side.  Upon  the  front  of  the 
ankle  the  artery  lies  beneath  the  anterior  annular  ligament,  having. 


LEG. 


493 


"the  tendon  of  the  extensor  longus  pollicis  on  its  inner  side  and  the 
tendons  of  the  extensor  longus  digit orum  on  its  outer  side.  Upon 
the  front  of  the  ankle  the  tendon  of  the  tibialis  anticus  lies  to  the 
inner  side  of  the  tendon  of  the  extensor  longus  pollicis,  and  the 
perineus  tertius  lies  to  the  outer  side  of  the  tendons  of  the  ex- 
tensor longus  digitorum.  After  the  anterior  tibial  artery  emerges 
from  beneath  the  lower  border  of  the  anterior  annular  ligament, 
it  is  continued  downward  as  the  dorsalis  pedis,  lying  in  the  first 
interosseous  space,  and  giving  off  a  branch  which  passes  outward 
across  the  tarsus,  and,  lower  down,  one  which  passes  outward  across 
the  heads  of  the  metatarsal  bones.     This  latter  branch,  which  is 


ANT.  TIB. 


SAPH  V£/A/ 


Fig.  203.— Section  through  the  Middle  of  the  Left  Leg. 


known  as  the  metatarsal,  gives  off  three  descending  branches,  which 
pass  downward  upon  the  second,  third,  and  fourth  interosseous  mus- 
cles as  far  as  the  webs  of  the  toes,  where  they  each  divide  into  two 
lateral  branches,  which  are  distributed  to  the  contiguous  halves  of 
the  adjoining  toes.  These  interosseous  branches  are  for  the  supply 
of  the  adjoining  sides  of  the  fifth  and  fourth,  fourth  and  third,  and 
third  and  second  toes.  The  dorsalis  pedis  itself  descends  upon  the 
first  interosseous,  this  part  of  the  artery — i.e.,  between  the  first  and 
second  metatarsal  bones — being  called  the  dorsalis  hallucis;  it  divides 
to  supply  the  contiguous  sides  of  the  first  (big  toe)  and  second  toes, 
supplying  also  the  inner  side  of  the  big  toe. 


494  LOWER  EXTREMITY. 

The  first  dorsal  interosseous  muscle  is  perforated  above  by  a 
large  branch  of  the  dorsalis  pedis,  which  passes  through  to  the  deep 
part  of  the  sole  of  the  foot,  to  anastomose  with  the  external  branch 
of  the  posterior  tibial  to  form  the  plantar  arch. 

The  Anterior  Tibial  Nerve,  which  is  derived  from  the  external 
popliteal,  reaches  the  anterior  tibial  artery  at  the  junction  of  the  upper 
and  middle  thirds  of  the  leg,  and  then  accompanies  it  throughout  the 
rest  of  its  course.  The  nerve  reaches  the  anterior  tibial  artery,  as  this 
vessel  lies  upon  the  interosseous  membrane,  by  curving  around  the 
upper  part  of  the  fibula  beneath  the  extensor  longus  digitorum.  Cor- 
responding to  the  middle  third  of  the  leg,  the  nerve  lies  upon  the 
front  of  the  artery,  but  in  the  lower  part  of  the  leg  it  lies  to  the 
outer  side  of  the  artery,  and  beneath  the  anterior  annular  ligament 
divides  into  an  internal  and  an  external  branch. 

Ligation  of  the  Anterior  Tibial  Artery. — The  patient  lies 
upon  the  back,  with  the  knee  somewhat  flexed  and  a  sand  bag  placed 
beneath  it.  The  linear  guide  to  the  artery  corresponds  to  a  line  drawn 
from  the  inner  side  of  the  head  of  the  fibula  to  a  point  below,  midway 
between  the  internal  and  external  malleoli. 

The  vessel  may  be  tied  in  the  middle  third  of  the  leg,  as  it  lies 
upon  the  anterior  surface  of  the  interosseous  membrane  between  the 
tibialis  anticus  on  its  inner  side  and  the  extensor  proprius  pollicis  on 
its  outer  side. 

An  incision,  about  two  fingers'  breadth  external  to  the  prominent 
edge  of  the  shin  bone  and  two  or  three  inches  long,  is  made  through 
the  skin  and  fat  down  to  the  deep  fascia.  The  deep  fascia  is  then  in- 
cised, and  working  down,  between  the  tibialis  anticus  on  the  inner  side 
and  the  extensor  proprius  pollicis  on  the  outer  side,  with  the  handle  of 
the  scalpel,  the  interosseous  membrane  is  reached.  The  foot  is  then 
somewhat  flexed  at  the  ankle — dorsal  flexion — to  relax  the  muscles, 
and  retractors  are  introduced  deep  into  the  wound,  and  the  artery, 
with  its  venae  comites  lying  upon  it,  is  exposed.  The  anterior  tibial 
nerve  lies  in  front  of  the  anterior  tibial  vessels  in  this  part  of  their 
course.  After  the  nerve  has  been  separated  from  the  artery  a  liga- 
ture is  carried  around  the  vessel  from  without  inward  and  tied. 

The  Posterior  Tibial  Artery. — This  vessel  passes  down  the  back 
of  the  leg,  and  below,  between  the  internal  malleolus  and  the  tuber- 
osity of  the  os  calcis,  it  divides  into  the  internal  and  external  plantar. 
The  posterior  tibial  is  larger  than  the  anterior,  and  at  its  origin  lies 
deep  beneath  the  muscles  of  the  calf, — gastrocnemius  and  soleus, — 


LEG.  495 

resting  upon  the  tibialis  posticus;  from  its  origin,  as  it  descends,  it 
gradually  approaches  the  tibial  side  of  the  leg. 

In  the  lower  third  of  the  leg  the  artery  is  more  superficial,  run- 
ning parallel  with  the  inner  border  of  the  tendo  Achillis  and  being 
covered  only  by  the  deep  fascia  and  the  integument.  The  posterior 
tibial  artery  is  accompanied  by  two  large  venae  comites,  one  on  either 
side  of  it. 

Between  the  os  calcis  and  the  inner  malleolus,  and  beneath  the 
origin  of  the  adductor  pollicis,  the  posterior  tibial  artery  divides  into 
its  terminal  branches,  the  internal  and  external  plantar.  The  in- 
ternal plantar,  the  smaller,  runs  along  the  inner  side  of  the  sole  of  the 
foot.  The  external  plantar  passes  outward,  beneath  the  flexor  brevis- 
digitorum,  lying  upon  the  flexor  accessorius  as  far  as  the  base  of  the 
fifth  metatarsal  bone;  it  then  turns  and  runs  inward  to  the  interval 
between  the  bases  of  the  first  and  second  metatarsal  bones,  where  it 
anastomoses  with  the  large  perforating  branch  from  the  dorsalis  pedis,, 
and  thus  forms  the  plantar  arch. 

From  the  plantar  arch  four  digital  branches  descend  in  the  corre- 
sponding interosseous  spaces  as  far  as  the  webs  of  the  toes,  where  they 
divide  for  the  supply  of  the  adjacent  sides  of  the  toes.  The  contig- 
uous sides  of  the  big  toe  and  second  toe  and  the  inner  side  of  the  big 
toe  are  supplied  by  the  continuation  of  the  perforating  branch  of  the 
dorsalis  pedis,  which  divides,  at  the  cleft  between  the  big  and  second 
toes,  into  two  branches.  One  passes  inward  to  supply  the  inner  border 
of  the  great  toe  and  the  other  bifurcates  to  supply  the  contiguous  sides- 
of  the  great  and  second  toes. 

As  the  posterior  tibial  artery  descends  in  the  middle  of  the  space 
between  the  os  calcis  and  the  internal  malleolus,  the  vense  comites 
lie  one  on  each  side  of  it;  the  posterior  tibial  nerve,  already  di- 
vided into  the  internal  and  external  plantar,  lies  to  its  outer  side; 
still  more  externally,  close  to  the  os  calcis,  is  the  tendon  of  the  flexor 
longus  pollicis,  and  to  the  inner  side  of  the  artery,  lodged  in  the  groove 
upon  the  posterior  border  of  the  internal  malleolus,  are  the  ten- 
dons of  the  tibialis  posticus  and  flexor  longus  digitorum;  of  these 
two,  the  tibialis  posticus  being  the  more  internal  and  the  closer  to  the 
bone. 

Just  below  its  origin  the  posterior  tibial  artery  gives  off  a  large 
branch,  the  peroneal;  this  branch  descends  along  the  fibular  side  of 
the  back  of  the  leg,  covered  by  the  spleus  and  gastrocnemius  and 
lying  upon  and  partly  covered  by  the  flexor  longus  pollicis. 


496  LOWER  EXTREMITY. 

The  Posterior  Tibial  Nerve  accompanies  the  posterior  tibial 
artery;  it  is  the  continuation  of  the  internal  popliteal,  and  is  a  large 
nerve.  At  its  commencement  the  nerve  lies  to  the  inner  side  of  the 
artery,  but,  a  short  distance  from  its  origin  the  artery  passing  ob- 
liquely inward  toward  the  tibial  side  of  the  leg  and  the  course  of  the 
nerve  being  straight,  the  nerve  thereby  gets  to  lie  to  the  outer  side 
of  the  artery.  The  posterior  tibial  nerve  continues  down  the  back  of 
the  leg  upon  the  outer  side  of  the  artery,  and  divides,  in  the  space 
between  the  os  calcis  and  the  internal  malleolus,  into  the  internal  and 
external  plantar. 

Ligation  oe  the  Posteeioe  Tibial. — This  vessel  may  be  exposed 
and  tied  just  above  the  ankle-joint  and  to  the  inner  side  of  the  tendo 
Achillis.  An  incision  is  made  about  two  inches  long  midway  between 
the  posterior  border  of  the  inner  malleolus  and  the  inner  border  of 
the  tendo  Achillis.  This  incision  reaches  through  the  integument 
and  fat  down  to  the  deep  fascia.  The  deep  fascia  is  then  incised  and 
the  posterior  tibial  artery  exposed;  it  is  found  quite  superficial,  to- 
gether with  its  venae  comites,  one  on  either  side.  To  the  outer  side  of 
the  vessels,  nearer  the  tendo  Achillis,  is  the  posterior  tibial  nerve. 
The  veins  are  separated  from  the  artery,  and  a  ligature  then  carried 
around  the  artery  in  an  aneurism  needle,  from  within  outward  in 
order  to  avoid  the  nerve,  and  tied. 

Tenotomy. — This  operation  is  done  with  a  narrow-bladed  knife 
through  a  very  small  incision  in  the  skin. 

Tendo  Achillis. — The  foot  is  strongly  flexed  so  as  to  put  the 
tendon  upon  the  stretch,  and  a  narrow  tenotomy  knife  entered  close 
to  the  inner  border  of  the  tendon  and  about  one  and  one-half  inches 
above  its  attachment  to  the  os  calcis;  the  knife  is  entered  upon  the 
flat  and  pushed  through  the  soft  parts  in  front  of  the  tendon  as  far 
as  its  outer  border;  the  blade  of  the  knife  is  then  turned  so  that  its 
cutting  edge  is  directed  toward  the  tendon,  and  with  several  strokes 
the  tendon  is  divided.  The  division  of  the  tendon  is  really  accom- 
plished by  strongly  flexing  the  foot  and  thus  making  the  tendon  very 
tense  upon  the  sharp  edge  of  the  knife. 

There  is  no  danger  of  wounding  the  posterior  tibial  vessels  and 
nerve  if  the  blade  of  the  knife  is  introduced  close  to  the  inner  border 
of  the  tendon  (see  "Posterior  Tibial  Artery,"  etc.). 

Tendons  of  the  Tibialis  Posticus  and  Flexok  Longus  Digi- 
torum. — These  tendons  are  divided  as  they  descend  in  the  groove 
upon  the  posterior  border  of  the  internal  malleolus. 


LEG.  497 

The  inner  edge  of  this  groove,  which  marks  the  posterior  border 
of  the  internal  malleolus,  should  be  recognized  and  the  tenotomy  knife 
introduced  upon  the  flat,  so  that  it  enters  in  front  of  the  tendons, 
between  the  tendons  and  the  floor  of  the  groove  upon  the  posterior 
border  of  the  internal  malleolus.  The  knife  is  then  turned  so  that  its 
cutting  edge  is  directed  toward  the  tendons,  and  by  forcibly  flexing 
(dorsal  flexion)  the  foot  and  everting  it,  thus  making  the  tendon  tense, 
their  division  is  accomplished  (see  "Posterior  Tibial  Artery,"  etc.). 

Multiple  Ligature  of  the  Subcutaneous  Veins  of  the  Leg. — This 
operation  is  performed  for  varicose  veins  of  the  leg  with  or  without 
ulcer,  and  with  very  satisfactory  results. 

The  operation  may,  in  many  cases,  be  done  under  local  cocain 
anaesthesia,  a  few  drops  being  injected  into  each  region  just  before 
the  incision  is  made;  after  several  such  injections  have  been  made 
one  may  often  dispense  with  further  injections. 

An  elastic  band  is  first  applied  about  the  thigh,  half  way  between 
the  knee  and  the  hip,  and  sufficiently  tight  to  obstruct  the  venous  re- 
turn, but  not  tight  enough  to  interfere  with  the  arterial  current; 
this  serves  to  make  the  subcutaneous  veins  stand  out  more  promi- 
nently. 

A  small  incision,  usually  about  one-half  inch  long,  is  made  with 
a  sharp  knife  just  alongside  the  vein  selected  for  ligation,  care  being 
taken  not  to  wound  the  vein. 

After  the  vein  has  been  exposed  it  is  separated  from  its  connective 
tissue  bed  with  a  director,  and  a  fine  catgut  ligature  carried  around 
it  in  the  eye  of  a  small  blunt-pointed  ligature  carrier.  After  the  lig- 
ature has  been  tied  the  small  wound  in  the  skin  is  closed  with  a  single 
catgut  stitch. 

The  first  ligature  should  be  applied  to  the  internal  saphena 
upon  the  inner  aspect  of  the  thigh,  several  inches  above  the  level  of 
the  knee-joint,  and  the  successive  ligatures  placed  below  this  point, 
thus  gradually  working  down  toward  the  foot,  or,  if  an  ulcer  is  present, 
toward  the  ulcer.  Each  prominent  vein  is  thus  treated,  using  from 
ten  to  twenty  separate  ligatures,  according  to  the  number  of  veins  that 
are  involved. 

If  an  ulcer  is  present,  all  the  enlarged  veins  radiating  from  the 
ulcer  should  be  ligated,  and  then  the  ulcer  may  be  scraped,  and,  after 
it  has  been  thoroughly  disinfected,  covered  with  skin  grafts.  Any 
veins  that  are  cut  during  the  operation  should  be  caught  with  clamps 
and  tied  with  catgut. 


498 


LOWER  EXTREMITY. 


AMPUTATIONS,  RESECTIONS,  ETC. 

Surgical  Anatomy  of  the  Skeleton  of  the  Foot. — A  knowledge 
of  the  composition  and  articulations  of  the  skeleton  of  the  foot  is  of 
much  practical  value  in  performing  the  various  amputations  upon 
this  part. 

The  tarsus  is  made  up  of  two  rows — or,  better,  two  groups — of 
irregular-shaped  bones.  The  first  row  consists  of  the  os  calcis  and 
astragalus,  the  os  calcis  occupying  the  outer  side  of  the  foot  and  form- 
ing the  heel,  the  astragalus  being  on  the  inner  side  of  the  foot,  par- 


Fig.  204. — Right  Foot.     C,  Chopart  articulation;  C",  incision  for  Chopart  amputa- 
tion; L,  Lisfranc  articulation;  L',  incision  for  Lisfranc  amputation. 


tially  resting  upon  the  os  calcis  and  entering  into  the  formation  of 
the  ankle-joint.  The  anterior,  articular  surfaces  of  these  bones  are 
on  about  the  same  plane,  and  form  an  uninterrupted  line  from  the 
outer  to  the  inner  side  of  the  foot.  The  anterior,  articular  surface  of 
the  astragalus  is  convex,  and  is  located  above  and  to  the  inner  side  of 
that  of  the  os  calcis,  which  is  rather  concave. 

The  second  group  consists  of  the  cuboid,  which  is  on  the  outer 
side  of  the  foot,  articulating  with  the  os  calcis;  the  scaphoid,  which 
is  on  the  inner  side  of  the  foot,  articulating  behind  with  the  astragalus; 


AMPUTATIONS,  RESECTIONS,  ETC.  499 

and  the  three  cuneiforms.  This  second  group  presents  anteriorly  an 
irregular  row  of  articular  surfaces  which  is  convex  toward  the  toes, 
its  outer  end  being  about  one  inch  nearer  the  ankle-joint  than  its 
inner  end. 

We  next  come  to  the  metatarsal  bones,  five  in  number,  which 
articulate  as  follows:  The  two  outer,  those  of  the  little  toe  and  the 
fourth,  with  the  cuboid;  the  third,  middle  one,  with  the  external 
cuneiform;  the  second  with  the  middle  cuneiform;  and  the  first, 
that  of  the  big  toe,  with  the  internal  cuneiform.  The  base  of  the 
fifth  metatarsal  bone  presents  a  prominent  tuberosity,  which  pro- 
jects outward  and  is  easily  felt  underneath  the  skin;  this  is  an  im- 
portant surgical  guide.  The  second  metatarsal  bone  is  characterized 
by  its  base  projecting  backward,  into  the  tarsus,  beyond  the  bases  of 
the  adjoining  metatarsal  bones;  so  that  the  tarso-metatarsal  artic- 
ular line  is  interrupted  at  this  point. 

We  therefore  have  an  articular  junction  between  the  os  calcis  and 
astragalus  behind  and  the  cuboid  and  scaphoid  in  front,  which  we 
might  call  the  Chopart  joint.  Through  this  we  do  the  Chopart 
amputation.  The  inner  end  of  the  scaphoid  presents  a  prominent 
tuberosity,  which  is  readily  felt  beneath  the  skin  just  below  and  in 
front  of  the  tip  of  the  inner  malleolus;  this  tubercle  is  the  guide  to 
the  inner  end  of  the  Chopart  joint,  the  outer  end  of  the  joint  being 
located  one  thumb's  breadth  behind  the  tuberosity  which  marks  the 
base  of  the  fifth  metatarsal  bone. 

The  articular  line  between  the  tarsus  behind  and  the  metatarsus 
in  front  might  be  called  the  Lisfranc  junction.  This  line  is  curved, 
with  its  convexity  forward  toward  the  toes.  The  outer  end  of  the 
junction  corresponds  to  the  base  of  the  metatarsal  bone  of  the  little 
toe,  which  presents  a  prominent  tuberosity  that  may  be  readily  felt 
and  which  is  the  guide  to  the  joint.  The  inner  end  of  the  Lisfranc 
junction  is  lower  than  the  outer,  being  about  one  inch  nearer  the  toes, 
and  may  be  located  two  fingers'  breadth  in  front  of  the  tuberosity  of 
the  scaphoid. 

The  line  of  the  Lisfranc  articulation  is  interrupted  by  the  pro- 
jection of  the  base  of  the  second  metatarsal  bone  rather  less  than  one- 
fourth  inch  farther  into  the  tarsus  than  the  third  metatarsal,  and  again 
by  the  fact  that  the  articulation  between  the  first  metatarsal  (big 
toe)  and  the  internal  cuneiform  is  about  half  an  inch  lower,  nearer 
the  toe,  than  that  between  the  second  metatarsal  and  the  middle 
cuneiform. 


500  LOWER  EXTREMITY. 

Exaetictjlation  or  the  Big  Toe.  Oval  Method. — The  toe  is 
seized  with  the  left  hand  and  a  dorsal  incision  made  upon  the  head 
(lower  extremity)  of  the  metatarsal  bone,  commencing  about  one-half 
inch  above  the  metatarso-phalangeal  joint;  this  incision  is  carried 
straight  down  to  a  point  about  one-half  inch  beyond  the  web  of  the 
toe  and  then  around  the  toe,  cutting  everything  to  the  bone. 

One  should  remember  that  the  head  of  the  metatarsal  bone  of  the 
big  toe  is  large  and  requires  a  considerable  flap  to  cover  it.  The  cor- 
ners of  the  flap  are  seized  first  on  one  side  and  then  on  the  other, 
and  the  flap  dissected  away  from  the  bone.  Flexing  the  toe,  the 
joint  is  opened  upon  its  dorsal  aspect,  the  lateral  ligaments  being  di- 
vided, while  the  toe  is  pulled  first  to  one  side  and  then  to  the  other, 
and  finally  the  remaining  attached  soft  parts  are  separated,  cutting 
close  to  the  bone  and  from  within  outward.  Spurting  vessels  are 
clamped  and  tied  and  the  wound  closed  with  four  or  five  interrupted 
catgut  sutures.  A  small  drain  may  be  left  in  situ  for  two  days.  Am- 
putation of  the  other  toes  is  done  in  a  manner  analogous  to  the  above. 

ExARTICTJLATION"  OF  THE  BlG  TOE,  WITH  BEMOVAL  OF  THE  FlRST 

Metatarsal  Bone. — An  incision  is  made  which  begins  just  above  the 
tarso-metatarsal  joint,  articulation  of  the  metatarsal  with  the  internal 
cuneiform,  which  is  located  about  one  finger's  breadth  below  the 
tuberosity  of  the  scaphoid,  and  this  is  carried  down,  upon  the  dorsal 
surface  of  the  foot,  to  the  web  of  the  toe,  at  which  point  it  is  carried, 
in  the  form  of  an  oval,  around  the  toe  (see  Fig.  219).  This  incision, 
throughout  its  whole  extent,  reaches  to  the  bone.  The  edges  of  the 
incision  are  drawn  apart  with  retractors,  and  the  soft  parts  separated 
from  the  metatarsal  bone,  after  which  the  joint  above,  between  the 
metatarsal  and  internal  cuneiform  bones,  is  opened  and  the  meta- 
tarsal enucleated  out  of  its  bed  of  soft  parts,  cutting  with  the  edge 
of  the  knife  close  to  the  surface  of  the  bone. 

The  tendons  of  the  big  toe  are  cut  short  above  at  the  level  of  the 
tarso-metatarsal  joint.  It  is  unnecessary  to  use  a  tourniquet  in  this 
amputation.  Spurting  vessels  are  caught  and  tied,  and  after  the  bleed- 
ing has  been  checked  the  wound  is  closed  with  several  interrupted 
catgut  sutures.  The  incision  may  be  placed  upon  the  side  of  the  foot 
instead  of  upon  the  dorsum;  this  is  better  for  drainage,  but  the  scar 
is  not  so  well  located. 

Exarticulation  of  the  Little  Toe. — Amputation  of  the  little 
toe  and  its  metatarsal  bone  may  be  done  in  a  manner  similar  to  the 
preceding. 


AMPUTATIONS,  RESECTIONS,  ETC.  501 

Foe  Ingrowing  Toe-nail.  Removal  of  the  Offending  Half 
of  the  Nail.  —  This  operation  is  done  under  local  cocain  anaesthe- 
sia. A  rubber  band  is  tied  tight  around  the  root  of  the  toe  for  the 
purpose  of  confining  the  cocain  to  this  part  and  in  order  to  control 
the  hemorrhage.  The  end  of  a  sharp-pointed  scissors  is  pushed  under 
the  nail  and  down  the  middle,  as  far  as  the  root,  and  with  this  the  nail 
is  split.  The  half  of  the  nail  which  is  to  be  removed  is  then  grasped 
with  an  artery  forceps  and  torn  away  from  the  matrix. 

Cotting  Operation. — Cocain  anaesthesia.  A  rubber  band  is  tied 
around  the  root  of  the  toe.  The  soft  parts,  corresponding  to  the 
affected  side  of  the  toe,  are  transfixed  with  a  long,  narrow-bladed  knife 
and  excised.     The  incision  should  extend  backward  well  beyond  the 


Fig.  205.— Operations  for  Ingrowing  Toe-nail.  Solid  line  indicates  Cot- 
ting  operation.  Dotted  line  shows  line  of  incision  for  removal  of  half  of  the 
nail. 

root  of  the  nail.  In  addition,  the  corresponding  half  of  the  nail  may  be 
removed  as  described  above.  The  bleeding  digital  branch  upon  the 
outer  side  of  the  toe  may  be  clamped  and  tied.  Although  a  snug  band- 
age and  elevation  of  the  limb  usually  suffice  to  control  the  hemorrhage, 
still  it  is  wise  to  ligate  the  bleeding  point.  The  raw  surfaces  are  dis- 
infected and  covered  with  a  wad  of  gauze  and  a  bandage  applied. 

Amputation  theough  the  Tarso-metataesal  Aeticulation 
(Lisfeanc). — A  tourniquet  is  applied  just  above  the  knee.  The  right 
foot,  for  example.  The  foot  should  extend  over  the  end  of  the  table. 
The  guides  to  the  Lisfranc  joint  are,  on  the  outer  side  of  the  foot,  the 
prominent  base  of  the  fifth  metatarsal  bone  (little  toe)  and,  on  the 
inner  side,  the  base  of  the  first  metatarsal  (big  toe)  which  is  located 


502  LOWER  EXTREMITY. 

a  fingers  breadth  in  front  of  the  tuberosity  of  the  scaphoid.  The 
lower  part  of  the  foot  is  grasped  in  the  left  hand  (the  palm  of  the 
hand  applied  to  the  sole  of  the  foot),  with  the  thumb  upon  the  outer 
guide  and  the  index  finger  upon  the  inner  guide,  and  a  curved 
incision,  with  its  convexity  downward  toward  the  toes,  is  then  made; 
this  incision  extends  across  the  dorsum  of  the  foot,  from  its  outer 
to  its  inner  border,  commencing  and  ending  a  little  below  the  level 
of  the  joint,  so  that  when  the  skin  retracts  it  will  not  leave  the  ends 
of  the  bones  protruding  beyond  the  edge  of  the  flap  (see  Fig.  204). 
An  incision  is  then  carried  down,  along  the  outer  and  inner  borders  of 
the  foot,  from  either  end  of  the  dorsal  incision,  as  far  as  the  web  of  the 
toes. 

The  short  flap  which  has  been  marked  out  upon  the  dorsum  of 
the  foot  is  dissected  back  to  the  level  of  the  articulation  and  should 
include  only  the  integument  and  the  subcutaneous  fat. 

Now,  forcibly  flexing  the  foot,  the  extensor  tendons  on  the  dor- 
sum are  divided  to  the  bone  and  the  point  of  the  knife  inserted  into 
the  joint  behind  the  base  of  the  metatarsal  bone  of  the  little  toe,  and 
this  joint  thus  opened.  The  knife  is  then  carried  inward  across  the 
foot,  remembering  that  the  line  of  the  joint  is  not  straight,  but  con- 
vex, the  convexity  being  directed  forward  toward  the  toes. 

When  we  reach  the  point  where  the  base  of  the  metatarsal  bone 
of  the  second  toe  projects  into  the  tarsus,  the  edge  of  the  knife  is 
turned  backward  toward  the  ankle  for  about  one-fourth  inch,  and 
then,  again  turning  it  inward,  the  joint  between  the  base  of  the 
second  metatarsal  and  the  middle  cuneiform  is  opened.  The  edge  of 
the  knife  is  then  turned  forward  toward  the  toes,  and  carried  in  this 
direction  for  about  one-half  inch,  in  order  to  reach  the  level  of  the 
joint  between  the  first  metatarsal  (big  toe)  and  the  internal  cunei- 
form, which  is  then  also  opened. 

Flexing  the  foot  still  more  forcibly,  thus  causing  the  joint  to 
gape  widely,  the  metatarsus,  the  portion  of  the  foot  which  is  to  be 
amputated,  is  freed  with  the  point  of  the  scalpel  upon  its  deep  plantar 
aspect,  and  then,  with  the  long  knife,  and  cutting  close  to  the  bone, 
all  the  soft  parts  are  separated  upon  the  plantar  aspect  of  the  foot 
down  to  the  webs  of  the  toes,  at  which  point  the  long  plantar  flap  is 
cut  from  within  outward  and  the  amputation  is  complete. 

It  will  be  necessary  to  clamp  and  tie  the  dorsalis  pedis  upon  the 
dorsal  surface  of  the  foot,  near  the  inner  border,  and  in  the  large 
plantar  flap  the  branches  of  the  plantar  arch. 


AMPUTATIONS,  RESECTIONS,  ETC. 


503 


We  have  upon  the  dorsum  a  short,  semilunar  flap  which  is  com- 
posed of  skin  and  fat  only,  and  upon  the  plantar  aspect  a  long  flap 


Fig.  206.— Right  Foot,  Inner  Side.    C,  incision  for  Chopart;  L,  incision 
for  Lisfranc;  P,  incision  for  Pirogoff. 


Fig.  207.—  Right  Foot,  Outer  Side.     C,  incision  for  Chopart;  L,  incision 
for  Lisfranc;  P,  incision  for  Pirogoff. 


composed  of  all  the  structures  of  the  sole  of  the  foot.    The  edges  of 
these  flaps  are  brought  together  with  interrupted  catgut  sutures. 

In  amputating  the  left  foot  it  is  grasped  in  the  same  way  by  the 


504  LOWER  EXTREMITY. 

operator,  indicating  the  bony  guides  with  his  finger  and  thumb,  the 
incision  being  made  from  the  inner  toward  the  outer  border  of  the 
foot. 

Amputation  through  the  Medio-tarsal  Joint  (Chopart). — 
The  tourniquet  is  placed  around  the  limb  above  the  knee-joint.  The 
right  foot,  for  example.  The  foot  extends  over  the  end  of  the  table. 
The  guide  to  the  Chopart  joint,  on  the  inner  side  of  the  foot,  is  the 
tubercle  of  the  scaphoid;  on  the  outer  side  of  the  foot  we  measure  a 
thumb's  breadth  behind  the  tuberosity  which  marks  the  base  of  the 
fifth  metatarsal  bone,  in  order  to  locate  the  outer  end  of  the  joint.  The 
foot  is  grasped  with  the  left  hand,  as  described  in  the  Lisfranc,  the 
index  finger  on  the  inner  guide,  tubercle  of  scaphoid,  and  the  thumb 
marking  the  level  of  the  joint  externally. 

As  in  the  Lisfranc,  a  short  anterior  flap  is  marked  out  by  making 
a  dorsal  incision,  curved,  with  the  convexity  forward  toward  the  toes. 
This  incision  commences  at  the  outer  border  of  the  foot  rather  in 
front  of  the  line  of  the  joint  (nearer  the  toes)  and  ends  on  the  inner 
side  of  the  foot,  likewise  in  front  of  the  line  of  the  joint  (see  Fig.  204). 
From  either  end  of  this  dorsal  incision  a  lateral  incision  is  carried 
forward,  along  either  border  of  the  foot,  toward  the  toes. 

The  short  anterior  flap  is  now  seized  and,  including  only  the  skin 
and  fat,  is  reflected  back  a  little  beyond  the  line  of  the  joint.  For- 
cibly flexing  the  foot,  the  medio-tarsal  joint  is  then  opened,  from 
within  outward,  by  inserting  the  point  of  the  knife  into  the  joint 
immediately  behind  the  tubercle  of  the  scaphoid  so  as  to  enter  be- 
tween this  bone  and  the  head  of  the  astragalus;  then,  continuing 
outward  toward  the  outer  border  of  the  foot,  the  joint  between  the 
cuboid  and  the  os  calcis  is  opened,  care  being  taken  not  to  enter, 
by  mistake,  the  joint  between  the  astragalus  and  the  os  calcis. 

Flexing  the  foot  still  more  forcibly,  and  thus  causing  the  opened 
joint  to  gape,  the  plantar  ligaments,  which  bind  the  bones  together, 
are  divided  with  the  scalpel,  and  then  a  long  knife  is  introduced 
into  the  joint  and  the  long  plantar  flap  cut  with  a  sawing  motion, 
the  edge  of  the  knife  being  applied  close  to  the  bones,  thus  separat- 
ing all  the  plantar  soft  parts  from  the  bones  as  far  down  as  the 
heads  of  the  metatarsal  bones,  where,  with  a  cut  from  within  out- 
ward, the  long  plantar  flap  is  completed. 

It  is  necessary  to  catch  the  stump  of  the  dorsalis  pedis  near 
the  inner  side  of  the  foot,  upon  the  dorsal  surface,  and  the  branches 
of  the  plantar  arch  in  the  long  posterior  flap.     The  dorsal  flap  is 


AMPUTATIONS,  RESECTIONS,  ETC.  505 

short,  and  consists  of  skin  and  fat;  the  plantar  flap  is  long,  and  in- 
cludes all  the  soft  parts  of  the  sole  of  the  foot.  The  edges  of  the 
flaps  are  united  with  several  interrupted  catgut  or  silk-worm  gut 
sutures. 

In  operating  upon  the  left  foot  it  is  grasped  by  the  surgeon  in 
the  same  way,  the  incision  marking  out  the  dorsal  flap  being  made 
from  the  inner  toward  the  outer  border  of  the  foot. 

Owing  to  the  action  of  the  tendo  Achillis,  the  stump  which  re- 
sults is  very  apt,  after  a  time,  to  become  extended  at  the  ankle-joint; 
in  order  to  avoid  this  the  division  of  the  tendo  Achillis  has  been 
recommended.  This,  however,  helps  but  little,  and  many  surgeons 
have  discarded  this  method  of  amputation  entirely. 

Surgical  Anatomy  of  the  Ankle-joint. — The  ankle-joint  is  formed 
by  the  lower  ends  of  the  tibia  and  fibula  and  the  astragalus.  The 
lower  ends  of  the  tibia  and  fibula  are  bound  together  by  the  so-called 
interosseous  ligament,  thus  forming  an  arched  concavity  into  which 
the  articular  surface  of  the  astragalus  is  received.  The  outer  por- 
tion of  the  tibio-fibular  arch  is  formed  by  the  external  malleolus 
(lower  end  of  fibula),  which  extends  a  finger's  breadth  lower  than 
the  inner  malleolus;  the  vault  and  inner  buttress  of  the  arch  are 
formed  by  the  lower  articular  surface  of  the  tibia  and  the  inner 
malleolus.  The  articular  surface  of  the  tibia  is  broader  in  front  than 
behind. 

The  articular  surface  of  the  astragalus  presents  an  upper, 
smooth  surface,  which  slopes  downward  and  backward  and  which  is 
also  wider  in  front  than  behind,  and  is  continuous,  on  each  side,  with 
a  lateral,  smooth  facet  for  articulation  with  the  inner  and  outer 
malleoli. 

The  joint  is  provided  with  a  capsular  ligament,  which  is  de- 
scribed as  consisting  of  several  separate  portions.  Behind,  it  is 
very  thin  and  membranous,  but  is  thicker  in  front  and  upon  the 
sides. 

The  capsule  is  attached  above,  anteriorly  and  posteriorly,  to  the 
margin  of  the  tibia  and  fibula,  and  on  the  sides  to  the  margins  of  the 
inner  and  outer  malleoli;  below  it  is  attached  to  the  adjacent  rough 
surface  of  the  astragalus  and  the  os  calcis,  some  of  the  fibers  on  the 
inner  side  extending  forward  to  the  scaphoid. 

The  joint  is  provided  with  a  synovial  membrane,  which  is  applied 
to  the  inner  aspect  of  the  capsular  ligament. 


506  LOWER  EXTREMITY. 

EXARTICULATION  OF  THE  FOOT  AT  THE  ANKLE-JOINT   (StME). — 

The  right  foot,  for  example.  The  foot  should  extend  over  the  end  of 
the  table,  and  is  grasped  by  the  operator  with  the  left  hand.  An  in- 
cision is  made  which  commences  upon  the  external  malleolus,  just 
above  its  tip,  and  which  is  carried  straight  downward  and  around  the 
sole  of  the  foot  and  thence  upward  as  far  as  the  tip  of  the  internal 
malleolus;  this  incision  reaches  to  the  bone  throughout  its  course. 
A  second  incision  is  made  which  passes  across  the  front  of  the  ankle- 
joint  through  the  skin,  joining  the  ends  of  the  first  incision. 

Having  incised  the  integument  upon  the  front  of  the  ankle, 
the  extensor  tendons,  etc.,  are  exposed;  these  are  divided  and  the 
ankle-joint  entered  by  cutting  through  the  anterior  ligament.  In 
doing  this  one  should  not,  by  mistake,  enter  the  joint  between  the 
head  of  the  astragalus  and  the  scaphoid. 

After  the  anterior  ligament  has  been  freely  divided  the  foot  is 
strongly  flexed,  and  then  the  lateral  ligament,  upon  each  side,  is 
divided  close  to  the  bone.  The  joint  now  gapes,  and  while  a  con- 
stantly increasing  traction  is  made  upon  the  foot  the  tendons  of  the 
peronei  are  cut  on  the  outer  side  and  the  tendons  of  the  tibialis 
posticus,  etc.,  on  the  inner  side. 

Cutting  with  the  edge  of  the  knife  close  to  the  bone,  the  os 
calcis  is  then  dissected  out  of  its  bed,  drawing  the  foot  first  to  one 
side  and  then  to  the  other  as  this  dissection  progresses,  and  occa- 
sionally searching  with  the  finger  for  resisting  bands,  etc.,  that  inter- 
fere with  the  enucleation  of  the  bone.  One  should  avoid  button- 
holing the  flap,  especially  as  the  back  part  of  the  os  calcis  is  reached 
and  as  the  attachment  of  the  tendo  Achillis  is  being  separated  from 
the  bone;  the  posterior  tibial  vessels  in  the  inner  side  of  the  flap 
may  also  be  avoided  by  keeping  the  edge  of  the  knife  close  to  the 
bone. 

After  the  os  calcis  has  been  thus  enucleated  from  the  soft  parts 
of  the  heel  and  the  foot  removed,  the  flap  is  turned  up  and  dissected 
away  from  the  lower  margin  of  the  tibia  and  fibula  for  a  short  dis- 
tance, in  order  to  make  way  for  the  application  of  the  saw.  A  thin 
slice  of  the  lower  end  of  the  tibia  and  the  malleoli  are  then  removed. 
The  anterior  tibial  and  the  internal  and  external  plantar  vessels  are 
ligated  and  the  anterior  and  posterior  tibial  nerves  drawn  down  and 
cut  short,  as  are  also  the  ends  of  any  divided  tendons  that  present 
themselves,  and  the  wound  then  closed  with  interrupted  catgut 
sutures. 


AMPUTATIONS,  RESECTIONS,  ETC.  507 

If  a  drain  is  used,  this  may  emerge  through  a  small  longitudinal 
incision,  which  is  made  in  the  posterior  part  of  the  flap  upon  the 
outer  side  of  the  tendo  Achillis.  Koenig  recommends  suture  of 
the  divided  anterior  tendons  to  the  edge  of  the  lower,  turned-up 
flap. 

Upon  the  left  foot  the  incision  would  he  made  from  the  tip  of 
the  internal  malleolus  around  the  sole  of  the  foot,  terminating  just 
ahove  the  tip  of  the  external  malleolus. 

EXARTICULATION  OF  THE  FOOT  AT  THE  ANKLE- JOINT  (PlROGOFF). 

— The  incisions  are  the  same  as  in  the  preceding  operation — the  Syme. 
After  the  ankle-joint  has  heen  freely  opened,  the  soft  parts  are 
separated  from  the  astragalus  and  the  os  calcis  backward,  beyond  the 
incision  that  passes  through  the  sole  of  the  foot,  as  far  as  the  poste- 
rior border  of  the  upper  articular  surface  of  the  astragalus.  The 
soft  parts  being  then  retracted,  the  saw  is  applied  to  the  upper  sur- 
face of  the  os  calcis  and  the  bone  cut  square  through  upon  a  plane  at 
right  angles  to  its  long  axis,  and  corresponding  to  the  incision  that 
passes  through  the  soft  parts  around  the  sole  of  the  foot. 

This  hooded  tegumentary  flap,  which  contains  the  posterior  por- 
tion of  the  os  calcis,  is  now  separated  from  the  lower  margin  of  the 
tibia  and  fibula,  working  close  to  the  surface  of  the  bones,  and  a 
thin  slice  of  the  lower  end  of  the  tibia,  together  with  both  malleoli, 
then  sawn  off.  This  section  is  made  upon  a  plane  at  right  angles 
to  the  long  axis  of  these  bones. 

The  anterior  tibial  and  the  internal  and  external  plantar  arteries 
are  ligated  and  the  corresponding  nerves  are  drawn  down  and  cut 
short. 

When  the  flap  is  brought  into  position,  the  sawn  surface  of  the 
os  calcis  and  the  sawn  surface  of  the  tibia  are  apposed;  the  edges 
of  the  wound  are  united  with  interrupted  catgut  sutures. 

If  drainage  is  desired,  it  may  be  provided  by  making  a  small 
longitudinal  opening  in  the  posterior  part  of  the  flap  along  the  outer 
side  of  the  tendo  Achillis.  If  the  traction  of  the  tendo  Achillis  upon 
the  segment  of  the  os  calcis  which  is  left  in  the  flap  is  considerable, 
the  tendon  may  be  divided  subcutaneously. 

Koenig  advises  suture  of  the  ends  of  the  cut  anterior  tendons 
to  the  edge  of  the  turned-up  flap  to  prevent  these  tendons  retracting 
up  the  leg,  and  also  to  hold  the  flap  in  position. 

The  sawn  surfaces  of  the  bones  are  usually  easily  retained  in 
apposition  by  the  bandage  and  dressings,  especially  if  the  tendo 


508 


LOWER  EXTREMITY. 


c£3 


Pig.  208.— Right  Foot,  Inner  Side.  A,  astragalus;  C,  os  calcis;  S,  sca- 
phoid; TA,  tendo  Aehillis.  Dotted  lines  show  lines  of  section  through  the 
bones  in  Pirogoff's  amputation. 


C=3 


Fig.  209. — Right  Foot,  Inner  Side.     Dotted  lines  show  section  through 
bones.     Giinther's  modification. 


e^LC^S 


Fig.  210.— Right  Foot,  Inner  Side.     Dotted  lines  rhow  section    through 
bones.    Le  Fort's  modification. 


AMPUTATIONS,  RESECTIONS,  ETC.  509 

Achillis  has  been  divided.  Some  surgeons  prefer  to  fix  the  segment 
of  the  os  calcis  to  the  lower  end  of  the  tibia  by  driving  a  nail  through 
the  os  calcis  into  the  lower  end  of  the  tibia. 

Gunther's  Modification  ,  of  Pirogoff's  Operation.  —  The  incision 
across  the  front  of  the  ankle  is  the  same  as  in  the  previous  opera- 
tion; the  lower  incision,  which  passes  through  the  sole  of  the  foot, 
instead  of  passing  vertically  downward  is  directed  obliquely  down- 
ward and  forward;  upon  the  inner  side  of  the  foot  this  incision  passes 
just  behind  the  tubercle  of  the  scaphoid,  and  a  similar  obliquity  is  also 
observed  upon  the  outer  side  of  the  foot,  the  incision  striking  just 
behind  the  tuberosity  of  the  base  of  the  fifth  metatarsal.  The  soft 
parts  are  dissected  back,  away  from  the  bones,  for  a  short  distance,  and, 
as  in  the  previous  operation,  the  ankle-joint  is  freely  opened  and  the 
saw  applied  to  the  upper  surface  of  the  os  calcis  behind  the  astragalus 
and  the  os  calcis  sawn  through,  not  straight  down  as  in  the  Pirogoff, 
but  obliquely  downward  and  forward  so  as  to  end  just  behind  the  an- 
terior edge  of  the  lower  surface  of  the  os  calcis. 

The  soft  parts  are  then  separated  from  the  lower  ends  of  the  tibia 
and  fibula,  and,  being  well  retracted,  the  lower  ends  of  these  bones 
are  sawn  off  obliquely  from  behind  forward  and  downward. 

The  sawn  surface  of  the  os  calcis  is  now  applied  to  the  sawn  sur- 
face of  the  tibia  without  any  rotation,  and  thus  division  of  the  tendo 
Achillis  is  avoided,  and,  further,  that  part  of  the  stump  which  sup- 
ports the  weight  and  is  applied  to  the  ground  corresponds  to  the  under 
surface  of  the  os  calcis  and  the  integument  covering  it. 

After  the  vessels  have  been  ligated  the  edges  of  the  wound  are 
brought  together  with  interrupted  catgut  sutures.  It  may  be  wise  to 
fix  the  stump  of  the  os  calcis  to  the  lower  surface  of  the  tibia  with  a 
nail,  which  is  driven  through  the  os  calcis  into  the  lower  end  of 
the  tibia,  previously  making  a  small  incision  in  the  skin  to  allow  the 
nail  to  be  introduced.  Drainage  may  be  provided  as  in  the  preceding 
operations. 

Le  Fort's  Modification  of  Pirogoff' s  Amputation.  —  A  slightly 
curved  dorsal  incision  is  made  across  the  foot,  corresponding  to  the 
Chopart  joint,  commencing  on  the  outer  side  of  the  foot  one  inch 
below  and  in  front  of  the  tip  of  the  external  malleolus  and  ending  on 
the  inner  side  of  the  foot  at  the  tubercle  of  the  scaphoid.  x\  second 
incision,  passing  obliquely  forward,  is  made  through  the  sole  of  the 
foot  as  in  Gunther's  operation,  uniting  the  ends  of  the  dorsal  in- 


510  LOWER  EXTREMITY. 

cisiori.  The  integument  is  then  dissected  back,  and  the  ankle-joint, 
under  forcible  flexion,  widely  opened  as  in  the  Pirogoff. 

The  upper  third  of  the  os  calcis,  through  a  plane  parallel  with 
the  long  axis  of  the  bone,  is  sawn  off;  this  section  through  the  os 
calcis  commences  at  the  posterior  end  of  the  bone,  after  first  sepa- 
rating the  soft  parts  and  the  tendo  Achillis  sufficiently  to  apply  the 
saw,  and  passes  forward  through  the  bone  as  far  as  the  Chopart 
joint  (articulation  between  the  os  calcis  and  cuboid).  The  foot  is 
then  removed,  leaving  the  remains  of  the  os  calcis,  with  the  tendo 
Achillis  attached,  in  the  flap.  The  lower  ends  of  the  tibia  and  fibula, 
after  proper  separation  and  retraction  of  the  soft  parts,  are  then 
sawn  off.  The  sawn  surfaces  are  apposed  and  the  wound  closed.  This 
is  a  rather  difficult  operation  to  perform. 

Amputation  of  the  Leg. — The  leg  may  be  amputated  at  any  point 
up  to  the  level  of  the  tuberosity  of  the  tibia.  With  a  view  to  the  use 
of  an  artificial  limb,  one  should  make  an  effort  to  save  the  knee-joint 
and  as  much  of  the  length  of  the  leg  as  possible. 

In  amputating  the  leg  we  may  use  flaps  of  different  length,  a 
long  anterior  and  a  short  posterior,  or  the  reverse,  and  the  flaps  may 
consist  of  the  integument  only  or  may  include  the  muscular  tissue  as 
well.  The  circular  method  may  also  be  used  here,  a  flap  of  integument 
being  turned  back  like  a  cuff  to  the  point  where  the  muscle  and  bone 
are  to  be  divided,  and  if  necessary,  owing  to  the  bulging  of  the  muscles 
of  the  calf,  the  circular  tegumentary  flap  may  be  split,  on  one  or  both 
sides,  in  order  to  facilitate  its  reflection. 

It  seems  to  me  that  lateral  skin  flaps  of  equal  length,  cut  in  such 
fashion  as  to  bring  the  suture  line  behind  the  end  of  the  bone,  is 
the  preferable  operation, — the  so-called  lateral  hooded  flap, — yet  we 
should  not  commit  ourselves  to  any  particular  method,  but  take  the 
flaps  as  best  we  can  when,  thereby,  more  of  the  length  of  the  limb 
can  be  saved. 

Amputation  of  the  Leg  with  Lateral  Hooded  Flaps. — The 
tourniquet  is  placed  above  the  knee.  The  patient  lies  with  the  leg  pro- 
jecting over  the  end  of  the  table  and  steadied  by  an  assistant,  who 
grasps  it  by  the  foot  and  elevates  it.  We  must  first  decide  upon  the 
point  at  which  the  bones  are  to  be  divided,  and  then  make  our  flaps  ac- 
cordingly (see  Fig.  212).  The  incision  is  commenced  on  the  front  of  the 
limb,  one  and  one-half  inches  below  the  level  at  which  the  bones  are 
to  be  divided  and  just  to  the  outer  side  of  the  sharp  anterior  border 
of  the  tibia;   from  this  point  the  incision,  curves  downward  and  back- 


AMPUTATIONS,  RESECTIONS,  ETC. 


511 


ward  around  either  side  of  the  leg,  approaching  the  middle  line  on 
the  posterior  aspect  of  the  limb,  where  it  is  carried  upward,  in  the 
middle  line,  to  a  point  opposite  the  level  at  which  the  bones  are  to  be 
divided.  This  incision  extends  through  the  skin  and  subcutaneous  fat 
down  to,  but  not  including,  the  deep  fascia. 

Each  of  the  lateral  flaps  thus  marked  out  should  correspond  in 
length  to  half  the  thickness  of  the  limb,  adding  one-third  to  allow 


Fig.  211. — Amputation  of  Leg.     Hooded  flap  of  skin  and  fat  turned  back. 
Arrow  shows  level  at  which  bones  are  to  be  divided. 


for  retraction.     The  length  of  the  flap  is  measured  from  the  level 
at  which  the  bones  are  to  be  divided. 

The  edge  of  the  flap  is  seized  with  the  fingers,  and,  making 
strong  traction,  it  is  separated  from  the  deep  fascia,  taking  all  the 
subcutaneous  fat  with  it  and  cutting  with  long  sweeps  of  the  knife, 
its  edge  being  always  directed  toward  the  deep  fascia  in  order  to 
avoid  cutting  the  small  vessels  that  ramify  in  the  fat  and  supply  the 
integument.  In  reflecting  the  flap  we  should  work  evenly  around 
the  whole  circumference  of  the  limb. 


512  LOWER  EXTREMITY. 

After  the  flaps  have  been  turned  back  as  far  as  the  level  at 
which  the  bones  are  to  be  sawn  through,  and  while  they  are  thus  held 
by  an  assistant,  the  muscles  are  divided  with  a  long  knife,  down  to 
the  bone,  with  one  clean,  circular  sweep.  The  muscular  tissue  be- 
tween the  bones  may  be  divided  with  a  narrow,  double  edged  knife 
or  with  a  scalpel  and  the  periosteum  then  incised  to  make  way  for 
the  saw. 

The  heel  of  the  saw  is  firmly  placed  upon  the  edge  of  the  tibia 
and,  drawing  back,  a  groove  is  made  in  which  the  saw  works  easily. 
When  the  tibia  is  partly  sawn  through  the  fibula  may  be  engaged 
in  order  to  complete  the  division  of  both  bones  simultaneously. 

The  use  of  the  three-tailed  cloth  retractor  may  be  dispensed 
with,  as  the  assistant  can  better,  with,  his  hands  or  with  sharp  re- 
tractors, hold  the  divided  muscles  out  of  the  way  of  the  saw. 

While  the  bones  are  being  sawn  the  limb  is  supported  below, 
that  its  weight  may  not  prematurely  break  the  bones  before  their 
section  with  the  saw  has  been  completed. 

The  prominent  anterior  angle  of  the  tibia  may  be  sawn  off  or 
chiseled  away,  although  this  is  probably  an  unnecessary  step,  espe- 
cially if  the  flaps  are  sufficiently  long.  The  end  of  the  fibula  may 
be  cut  a  little  shorter  with  the  bone  forceps.  In  shortening  the 
fibula  one  should  not  use  the  straight  bone  forceps,  as  they  rather 
crush  and  splinter  the  shaft  of  the  bone;  it  is  better  to  do  this  by 
taking  several  bites  with  a  sharp  rongeur. 

Before  removing  the  tourniquet  the  anterior  and  posterior 
tibial  vessels  are  clamped  and  tied.  The  anterior  tibial  is  found 
upon  the  front  of  the  interosseous  membrane  between  the  bones; 
the  anterior  tibial  nerve  may  be  pulled  down  and  cut  short  at  the 
same  time.  The  posterior  tibial  vessels  are  located  in  the  back  of 
the  stump,  on  the  tibial  side  of  the  leg,  beneath  the  gastrocnemius 
and  soleus  muscles;  the  large  nerve  which  accompanies  these  vessels 
may  be  pulled  down  and  cut  short.  The  peroneal  branch  of  the 
posterior  tibial  artery,  which  is  found  just  behind  the  fibula,  should 
also  be  tied.  After  the  tourniquet  has  been  removed  any  remaining 
vessels  that  bleed  may  be  caught  and  tied.  The  edges  of  the  flaps 
are  joined  with  interrupted  catgut  sutures,  leaving  a  drain  which 
emerges  posteriorly.  When  the  suture  is  complete,  it  will  be  seen 
that  the  suture  line  is  located  behind  the  end  of  the  tibia  and  thus 
out  of  the  way  of  pressure. 


AMPUTATIONS,  RESECTIONS,  ETC.  513 

Surgical  Anatomy  of  the  Knee-joint. — The  knee-joint  is  made 
up  of  the  lower  end  of  the  femur  and  the  upper  end  of  the  tibia  and 
the  patella.  The  lower  end  of  the  femur  is  expanded  and  rather 
cuboidal  in  form,  having  two  prominent  condyles  which  project  back- 
ward beyond  the  posterior  surface  of  the  shaft  of  the  bone. 

The  inner  condyle,  when  the  femur  is  held  perpendicularly,  is 
seen  to  extend  lower  than  the  outer  and  is  also  rather  narrower  than 
the  outer.  The  inferior  and  posterior  surfaces  of  the  condyles  are 
smooth,  rounded,  and  covered  with  cartilage;  this  smooth  articular 
surface  is  also  continued  upward  upon  the  anterior  surface  of  the 
lower  end  of  the  femur,  extending  rather  higher  externally  than 
internally,  and  is  limited  externally  by  a  prominent  ridge. 

Behind,  between  the  projecting  condyles,  there  is  a  space  large 
enough  to  accommodate  the  thumb,  known  as  the  intercondyloid 
notch;  to  the  contiguous  surfaces  of  this  notch  the  crucial  ligaments 
are  attached. 

The  inner  condyle  presents  upon  its  inner  surface  a  broad  promi- 
nence, the  inner  tuberosity,  and  to  this  the  internal  lateral  ligament 
is  attached. 

The  outer  condyle  presents  upon  its  outer  surface  a  prominent 
tubercle,  which  is  located  a  little  behind  the  center,  and  to  this  is 
attached  the  external  lateral  ligament.  Immediately  below  this  tu- 
bercle there  is  a  .smooth  groove  in  which  the  tendon  of  the  popliteus 
muscle  is  lodged. 

The  lower  and  posterior  portions  of  the  articular  surface  of  the 
condyles  articulate  with  the  articular  surface  of  the  tibia;  the  ante- 
rior portion  articulates  with  the  patella.  The  relation  of  these 
articular  surfaces  varies  according  to  the  position  of  the  knee-joint. 

The  upper  end  of  the  tibia  presents  a  superior  surface,  which 
is  divided  into  two  lateral  concave,  rather  ovoidal  portions,  which 
articulate  with  the  condyles  of  the  femur,  and  an  intermediate  rough 
area  which  is  marked  by  a  prominence,  the  spinous  process,  the  sum- 
mit of  which  presents  two  prominent  tubercles  for  the  attachment 
of  the  extremities  of  the  semilunar  interarticular  fibro-cartilages. 
This  intermediate  space,  in  front  and  behind  the  spinous  process,  is 
rough  for  the  attachment  of  the  semilunar  cartilages  and  the  crucial 
ligaments. 

The  anterior  surface  of  the  upper  end  of  the  tibia  presents  a 
triangular  surface,  its  baee  corresponding  to  the  anterior  border  of 
the  upper  surface  of  the  tibia  and  its  apex  to  the  tuberosity  of  the 


514  LOWER  EXTREMITY. 

tibia.  The  tuberosity  of  the  tibia  gives  attachment  to  the  liga- 
mentum  patella?. 

The  patella  presents  a  smooth  posterior  surface,  covered  with 
cartilage,  which  articulates  with  different  parts  of  the  articular  sur- 
face of  the  condyles  in  different  positions  of  the  knee-joint. 

The  upper  and  lateral  borders  of  the  patella  give  attachment  to 
the  expanded  tendon  of  the  quadriceps;  the  lower  part  of  the  poste- 
rior surface,  which  is  rough,  gives  attachment  to  the  ligamentum 
patella?.  This  ligament,  which  is  attached  below  to  the  tubercle  of 
the  tibia,  fixes  the  patella  to  this  bone. 

The  anterior  surface  of  the  patella  is  smooth  and  is  covered  by 
a  fibrous  expansion  from  the  quadriceps  extensor,  and  is  separated 
from  the  integument  by  a  bursa  which,  at  times,  becomes  inflamed — 
housemaid's  knee. 

The  knee  is  provided  with  a  capsular  ligament  which  is  thin  or 
wanting  in  places,  and  is  strongly  reinforced  by  expansions  derived 
from  the  deep  fascia  (lata)  and  from  the  quadriceps  and  by  various 
accessory  ligaments. 

In  front  is  the  ligamentum  patella?.  Behind  is  the  ligament  of 
Winslow,  which  forms  the  posterior  part  of  the  capsule;  this  liga- 
ment is  strong,  and  extends  between  the  femur  and  the  tibia  and  is 
strengthened  by  bands  from  the  tendon  of  the  semimembranosus, 
which  pass  upward  and  outward  from  the  inner  tuberosity  of  the 
tibia  to  the  external  condyle  of  the  femur;  it  forms  part  of  the  floor 
of  the  popliteal  space,  and  the  popliteal  vessels  lie  close  to  it. 

The  origins  of  the  gastrocnemius,  plantaris,  and  popliteus  mus- 
cles are  intimately  connected  with  the  posterior  ligament. 

Laterally,  upon  the  inner  side  of  the  joint,  we  have  the  in- 
ternal lateral  ligament,  which  extends  from  the  tuberosity  of  the 
internal  condyle  to  the  upper  part  of  the  internal  border  of  the 
tibia,  and  upon  the  outer  side  the  external  lateral  ligament,  which 
is  attached  above  to  the  tubercle  on  the  external  condyle  and  below 
to  the  head  of  the  fibula.  These  lateral  ligaments  are  attached  be- 
hind the  center  of  the  condyles,  and  are  therefore  put  upon  the 
stretch  by  any  attempt  at  overextension  of  the  knee-joint.  The  cap- 
sule is  further  reinforced,  on  the  sides,  by  the  broad  expansions  that 
are  derived  from  the  quadriceps  extensor  and  the  fascia  lata;  these 
are  attached  to  the  sides  of  the  patella. 

Within  the  joint  are  the  ligamenta  alaria,  which  are  simply 
redundant  folds  of  the  synovial  membrane  that  are  reflected  from 


AMPUTATIONS,  RESECTIONS,  ETC.  515 

the  sides  of  the  patella;  these  are  prolonged  downward  and  hack- 
ward  as  the  ligamentum  mucosum,  which  is  attached  hehind  to  the 
femur  in  the  intercondyloid  notch  between  the  condyles. 

The  crucial  ligaments,  two  in  number,  pass  between  the  lower 
end  of  the  femur  and  upper  surface  of  the  tibia,  crossing  one  an- 
other, and  help  to  fix  the  bones.  The  internal  passes  from  the  outer 
side  of  the  internal  condyle  downward,  backward,  and  outward,  and 
is  attached  to  the  rough  portion  of  the  upper  surface  of  the  tibia 
behind  the  spine.  The  external  extends  from  the  inner  side  of  the 
external  condyle  downward,  forward,  and  inward  and  is  attached  to 
the  rough  space  in  front  of  the  spine  of  the  tibia. 

Within  the  joint,  interposed  between  the  articular  surfaces  of 
the  femur  and  tibia,  are  the  two  semilunar  fibro-cartilages,  the  in- 
ternal and  the  external.  Placed  upon  the  upper  surface  of  the  tibia, 
they  serve  to  deepen  the  concavity  which  receives  the  articular  sur- 
face of  the  femur.  They  are  semilunar  in  form,  and  are  attached 
by  their  borders  to  the  margin  of  the  upper  surface  of  the  tibia  and 
to  the  inner  contiguous  surface  of  the  capsule;  by  their  extremities 
they  are  attached  to  the  rough  middle  portion  of  the  upper  surface 
of  the  tibia  between  the  two  articular  surfaces. 

The  synovial  membrane  of  the  knee-joint  is  very  extensive;  it 
lines  the  inner  surface  of  the  capsule  and  gives  off  a  large  pouch, 
which  extends  upward  upon  the  front  of  the  femur  beneath  the 
quadriceps  extensor;  as  the  ligamenta  alaria,  the  synovial  membrane 
is  reflected  from  the  sides  of  the  patella  and  is  continued  backward 
as  a  process,  the  ligamentum  mucosum,  to  the  back  of  the  femur, 
between  the  two  condyles,  where  it  is  attached.  The  synovial  mem- 
brane lines  both  surfaces  of  the  semilunar  cartilages  and  invests  the 
crucial  ligaments,  and  often  communicates  with  the  synovial  lining 
of  the  tibio-fibular  joint  and  with  the  bursa?  adjacent  to  the  knee- 
joint.  It  gives  a  process  externally  which  is  found  between  the 
margin  of  the  external  semilunar  cartilage  and  tendon  of  the  pop- 
liteus  muscle,  forming  a  bursa  for  this  tendon.  A  pad  of  fat  is 
wedged  into  the  joint  below  the  patella,  being  covered  by  the  syno- 
vial membrane  of  the  joint  and  prolonged  into  the  ligamentum 
mucosum. 

The  Buks^e  Adjacent  to  the  Knee-joint. — The  arrangement 
of  the  bursas  about  the  knee-joint  is  somewhat  irregular. 

Posteriorly.     On  the  outer  side:    First.    Between  the  posterior 


516  LOWER  EXTREMITY. 

part  of  the  capsule  and  the  outer  head  of  the  gastrocnemius  there 
is  a  bursa  which  sometimes  communicates  with  the  joint. 

Second.  Beneath  the  tendon  of  the  popliteus  there  is  a  bursa 
which  always  communicates  with  the  joint. 

Third.  Occasionally  there  is  a  bursa  between  the  tendon  of 
the  popliteus  and  the  external  lateral  ligament. 

Inner  side:  First.  Between  the  inner  head  of  the  gastrocnemius 
and  the  posterior  part  of  the  capsule  there  is  a  bursa  which  often 
communicates  with  the  joint  and  sends  a  process  between  the  gas- 
trocnemius and  the  semimembranosus. 

Second.  Between  the  semimembranosus  and  the  head  of  the 
tibia. 

Third.  Occasionally  between  the  tendons  of  the  semitendinosus 
and  semimembranosus. 

Anteriorly.  First.  Between  the  anterior  surface  of  the  patella 
and  the  integument. 

Second.  Between  the  ligamentum  patellae  and  anterior  surface 
of  the  tibia  (tubercle  tibiae). 

EXAKTICULATION"    OF    THE    LEG    AT    THE    KNEE-JOINT    (STEPHEN" 

Smith  Hooded  Flap). — The  patient  lies  upon  his  back,  with  the  leg 
overhanging  the  end  of  the  table.  One  should  remember  that  the  end 
of  the  femur  is  large  and  that  a  considerable  flap  is  required  to  cover 
it.     The  tourniquet  is  placed  above  the  knee,  high  up. 

The  incision,  which  passes  through  the  integument  and  fat  down 
to  the  deep  fascia,  commences  in  front,  one  inch  below  the  tubercle 
of  the  tibia;  from  this  point  it  curves  downward  and  backward  across 
either  side  of  the  leg,  and  behind,  near  the  middle  line,  is  carried 
upward  into  the  popliteal  space  as  high  as  the  level  of  the  knee- 
joint.  Two  lateral  flaps  with  rounded  corners  are  thus  marked  out. 
One  should  avoid  making  the  flap  scant  by  getting  well  upon  the 
posterior  aspect  of  the  leg  before  turning  the  incision  upward  into 
the  popliteal  space. 

This  tegumentary  flap,  which  includes  the  subcutaneous  fat,  is 
now  seized  with  the  fingers  and  dissected  away  from  the  deep  fascia 
with  long  sweeps  of  the  knife,  its  edge  being  directed  toward  the 
deep  fascia  so  as  not  to  cut  into  the  flap.  Considerable  traction 
should  be  applied  to  the  flap  as  it  is  being  reflected,  in  order  to  facili- 
tate its  separation  from  the  deep  fascia.  The  flap  should  be  dis- 
sected up  to  the  level  of  the  joint  all  around.  While  the  flap  is 
retracted  the  knee-joint  is  sharply  flexed  and  entered,  cutting  first 


AMPUTATIONS,  RESECTIONS,  ETC.  517 

through  the  lower  part  of  the  ligamentum  patellar;  the  blade  of  the 
knife  is  then  introduced,  flatwise,  between  the  semilunar  fibro-carti- 
lages  and  the  upper  surface  of  the  tibia,  and  the  cartilages  separated 


Fig.  212.— Right  Leg,  Outer  Side.  A,  outline  of  hooded  skin  flap  in  am- 
putation of  the  leg.  Dotted  line  shows  line  of  division  through  bones.  B, 
outline  of  skin  flap  in  Stephen  Smith  hooded  flap  for  exarticulation  at  the 
knee-joint. 

all  around  from  the  edge  of  the  upper  surface  of  the  tibia,  so  that 
they  may  be  left  attached  in  the  stump  after  the  leg  has  been  am- 
putated. 


518  LOWER  EXTREMITY. 

The  lateral  ligaments  are  cut  on  each  side,  and  with  the  limb 
still  strongly  flexed  the  attached  ends  of  the  fibro-cartilages  and  the 
crucial  ligaments  are  cut  away  from  the  upper  surface  of  the  tibia, 
and  then,  with  a  long  knife,  the  soft  parts  behind  the  joint,  the 
posterior  ligament,  popliteal  vessels,  etc.,  and  tendons  and  muscle, 
are  cut  square  through  from  within  the  joint.  The  amputation  is 
thus  complete. 

The  popliteal  artery  and  its  vein,  which  lies  upon  (superficial 
to)  it,  are  each  seized  and  tied.  They  lie  close  to  the  posterior  sur- 
face of  the  femur.  The  popliteal  nerves  are  pulled  down  and  cut 
short.  The  edges  of  the  flap  are  united  with  interrupted  catgut  su- 
tures, a  space  being  left  posteriorly  for  drainage. 

This  operation  gives  us  a  good,  broad,  fairly  flat  stump,  with 
the  suture  line  behind  the  extremity  of  the  bone.  The  reason  for 
leaving  the  fibro-cartilages  in  the  stump  is  that  they  tend  to  make  a 
better  base  to  the  end  of  the  femur. 

Transcondylar  Amputation  at  the  Knee-joint  (Caeden). — 
A  long  anterior  and  a  short  posterior  flap  are  made,  the  femur  being 
divided  through  the  condyles.  Both  legs  hang  over  the  end  of  the 
table,  the  one  to  be  amputated  being  extended  and  supported  by  an 
assistant,  who  grasps  the  foot.  In  amputating  the  right  limb  the 
operator  stands  on  the  outer  side  of  the  leg  and  with  the  thumb  and 
forefinger  indicates  the  points  at  which  the  incision  commences  and 
ends. 

A  long  anterior  flap  is  marked  out  by  an  incision  which  passes 
through  the  skin  and  subcutaneous  fat  down  to  the  deep  fascia. 
This  incision  commences  at  a  point  a  little  behind  the  middle  of 
the  internal  condyle  and  upon  a  level  with  the  knee-joint;  it  passes 
down  the  inner  side  of  the  leg  as  far  as  the  tubercle  of  the  tibia, 
swings  outward  across  the  front  of  the  leg,  passing  below  the  tubercle 
of  the  tibia,  and  is  then  carried  upward  upon  the  outer  side  of  the 
leg  to  a  point  upon  the  outer  condyle  opposite  that  at  which  the 
incision  began  upon  the  inner  condyle. 

In  operating  upon  the  left  leg  the  operator  may  stand  upon  the 
inner  side  of  the  limb,  making  the  incision  from  the  outer  condyle 
around  to  the  inner.  The  corners  of  the  flap  should  be  rounded,  but 
the  flap  should  not  be  tongue-shaped. 

The  edge  of  the  anterior  flap  is  seized  with  the  fingers,  and  the 
flap,  consisting  of  the  skin  and  subcutaneous  fat,  is  dissected  away 
from  the  deep  fascia  and  reflected  as  far  as  the  lower  border  of  the 


AMPUTATIONS,  RESECTIONS,  ETC. 


519 


patella;  in  thus  detaching  the  tegumentary  flap  the  edge  of  the  knife 
should  always  be  directed  toward  the  deep  fascia.     The  knee  is  then 


Fig.   213. — Right  Leg.     Carden's  Amputation.     Solid   line   indicates   flaps. 
Dotted  line  shows  line  of  division  through  the  condyle. 

flexed  and  the  joint  opened  from  in  front  with  the  long  knife,  which 
first  divides  the  ligamentum  patellae  and  then  passes  straight  through 


Fig.  214. — Stump  After  Carden's  Amputation. 

the  joint,  cutting  capsule,  lateral  ligaments,  and  crucial  ligaments, 
and  emerging  through  the  structures  in  the  popliteal  space;  as  the 
knife  passes  through  the  integument  in  the  popliteal  space  the  assist- 


520  LOWER  EXTREMITY. 

ant  should  draw  the  soft  parts  upward  toward  the  hip,  and  the  knife 
may  he  turned  somewhat  downward  in  order  that  the  posterior  flap 
may  not  be  cut  too  short,  as  the  integument  in  this  region  tends  to 
retract  very  much. 

The  soft  parts  are  then  separated  about  the  circumference  of  the 
condyles  and  retracted,  and  the  saw  applied,  the  section  being  made, 
not  above,  but  directly  through,  the  condyles  proper.  The  sharp 
edge  of  the  sawn  surface  of  the  condyles  may  be  rounded  off  somewhat 
with  a  file  or  with  a  rongeur  bone  forceps.  The  popliteal  artery  and 
vein  are  found  posterior  to  the  bone,  and  should  be  tied  separately 
and  the  popliteal  nerves  drawn  down  and  cut  short. 

The  stump  is  covered  over  by  joining  the  edges  of  the  long  ante- 
rior skin  flap  and  the  short  posterior  flap  with  interrupted  catgut  su- 
tures. It  is  wise  to  drain  the  synovial  pouch,  which  is  located  in  front 
of  the  lower  end  of  the  femur,  under  the  quadriceps  extensor,  by  in- 
troducing two  tubes,  which  reach  well  up  into  the  pouch,  emerging 
through  the  incision  on  either  side. 

Amputation  at  the  Knee-joint  (Gritti-Stokes). — The  posi- 
tion of  the  patient  is  the  same  as  described  in  Carden's  amputation.  A 
long  anterior  flap  is  marked  out  by  an  incision  commencing  upon  the 
internal  condyle  just  behind  its  middle,  and  passing  down  the  side  and 
then  across  the  front  of  the  leg  just  below  the  tubercle  of  the  tibia, 
and  thence  upward  to  a  point  on  the  outer  condyle  a  little  behind  its 
center.  The  flap  thus  outlined  is  like  the  Carden,  but  somewhat 
shorter.  The  edge  of  this  anterior  flap  is  seized  with  the  fingers  and, 
including  all  the  subcutaneous  fat,  is  separated  from  the  deep  fascia, 
cutting  with  the  edge  of  the  knife  directed  toward  the  deep  fascia  and 
constantly  making  considerable  traction  upon  the  flap.  At  the  lower 
border  of  the  patella,  the  flap  being  retracted  and  the  leg  flexed,  the 
knee-joint  is  opened  from  before  backward,  cutting  with  the  long  knife 
through  the  ligamentum  patellae,  capsule,  and  lateral  and  crucial  liga- 
ments, and  finally  through  the  posterior  ligaments  and  the  parts  in 
the  popliteal  space.  While  cutting  through  the  integument  in  the  pop- 
liteal space  the  skin  should  be  drawn  well  upward  toward  the  hip-joint 
so  that  the  posterior  flap  may  not  be  cut  too  short.  There  should  be 
a  short  posterior  flap,  one-half  to  one  inch  long. 

The  soft  parts  are  separated  from  the  lower  end  of  the  femur, 
working  with  the  edge  of  the  knife  close  to  the  bone,  to  a  point  beyond 
the  upper  limits  of  the  articular  surface;  here  a  circular  cut  is  made 
around  the  bone,  and  with  the  saw  the  end  of  the  femur  is  removed 


AMPUTATIONS,  KESECTIONS,  ETC. 


521 


parallel  with,  the  plane  of  its  inferior  articular  surface.  After  the 
articular  end  of  the  femur  has  been  removed,  the  patella,  being 
surrounded  by  a  towel  to  give  a  good,  firm  grip,  is  seized  with  the  left 
hand  and  the  whole  of  its  articular  surface  sawn  off.  The  sawn  sur- 
face of  the  patella  is  then  apposed  to  that  of  the  lower  end  of  the 
femur,  to  which  it  is  fixed  by  two  chromicized  catgut  sutures,  which 
are  passed  through  drill  holes  in  the  posterior  edge  of  the  femur  and 
the  lower  border  of  the  patella.  The  patella  may  also  be  fixed  to  the 
femur  by  a  nail  driven  through  it  into  the  femur.  The  popliteal 
vessels  require  ligation.     A  tube  may  be  introduced  on  each  side 


Fig.  215. 


-Gritti-Stokes  Amputation.     Solid  lines  indicate  flaps, 
lines  show  section  through  femur  and  patella. 


Dotted 


to  drain  the  large  synovial  space  under  the  quadriceps  extensor  ten- 
don. The  edges  of  the  wound  are  sutured  with  interrupted  stitches  of 
catgut. 

Amputation  of  the  Thigh. — As  a  rule,  this  is  accomplished  by 
a  modified  circular  in  two — or,  better,  three — steps,  the  skin  being 
divided  upon  one  level,  the  muscles  upon  another,  and  the  bone  upon 
a  third.  A  tourniquet  is  placed  about  the  limb,  high  up,  near  the 
hip-joint. 

The  thigh  should  hang  over  the  end  of  the  table.  For  either  the 
right  or  the  left  thigh  it  is  probably  more  convenient  for  the  operator 
to  stand  upon  its  outer  side.    An  assistant  steadies  the  thigh  by  grasp- 


522  LOWER  EXTREMITY. 

ing  it  above  and  drawing  the  integument  a  little  toward  the  hip.  A 
second  assistant  may  support  the  limb  below. 

The  point  at  which  the  bone  is  to  be  divided  is  first  located,  and 
then,  with  a  sweep  of  the  long  amputating  knife,  a  circular  incision 
is  made  around  the  limb  through  the  skin  and  fat  down  to  the  deep 
fascia,  thus  marking  the  lower  limits  of  the  skin  flap.  This  circular 
incision  in  the  skin  should  be  placed  below  the  point  at  which  the 
bone  is  to  be  divided  a  distance  equal  to  half  the  diameter  of  the  limb 
at  that  point  (where  the  bone  is  to  be  divided),  adding  one-third 
more  to  allow  for  retraction. 

The  edge  of  the  skin  flap  is  seized  with  the  fingers  and  the  flap 
reflected  like  a  cuff,  separating  it  from  the  underlying  deep  fascia 
with  long  sweeps  of  the  scalpel,  its  edge  being  always  directed  toward 
the  deep  fascia  in  order  to  avoid  cutting  into  the  flap.  While  the 
flap  is  being  dissected  away  from  the  deep  fascia,  upon  the  posterior 
aspect  of  the  thigh,  the  limb  may  be  elevated  by  the  assistant. 

After  the  flap  has  been  dissected  back  to  within  one  inch  of  the 
point  at  which  the  bone  is  to  be  divided,  the  long  knife  is  again  taken 
and  the  muscles  are  cut,  with  a  circular  sweep,  down  to  the  bone. 
The  muscular  tissue  is  then  scraped  back  away  from  the  bone  with 
a  blunt  instrument  as  far  as  the  point  at  which  the  bone  is  to  be 
divided.  While  the  assistant  retracts  the  skin  and  muscles  with  his 
hands  or  sharp  retractors,  a  circular  incision  is  made  through  the 
periosteum  around  the  bone,  and  then,  planting  the  heel  of  the  saw 
upon  the  bone,  it  is  drawn  firmly  backward,  thus  making  a  groove 
for  itself,  and  the  bone  is  then  quickly  severed;  the  assistant  sup- 
ports the  limb  lightly  below  in  order  that  the  bone  may  not  be 
broken  before  it  is  sawn  completely  through.  The  limb  should  not 
be  so  held  by  the  assistant  as  to  jam  the  saw. 

The  femoral  and  profunda  femoris  arteries  and  veins,  which  are 
located  close  to  the  inner  side  of  the  femur,  are  tied  separately,  and 
the  tourniquet  then  removed,  after  which  any  remaining  bleeding 
points  may  be  clamped  and  tied. 

While  seeking  these  bleeding  points  only  a  limited  part  of  the 
surface  of  the  stump  need  be  exposed  at  one  time,  the  rest  being 
covered  and  compressed  with  a  hot  gauze  pad.  The  chief  bleeding 
points  are  sought  between  the  muscles.  The  sciatic  nerve,  which  is 
found  between  the  muscles  on  the  back  of  the  thigh,  is  pulled  down 
and  cut  short. 

The  edges  of  the  flap  are  brought  together  from  side  to  side, 


AMPUTATIONS,  RESECTIONS,  ETC.  523 

making  a  transverse  line,  with  interrupted  catgut  sutures.  It  is 
usually  wise  ttf  leave  a  drain  for  several  days.  If  the  subject  is  very 
muscular  and  the  limb  very  thick,  it  may  be  necessary  to  incise  the 
flap  on  one  side  in  order  to  facilitate  its  reflection. 

This  is  probably  the  preferable  method  of  amputating  the 
thigh.  Instead  of  the  above  described  method,  one  may  use  a  long 
anterior  and  a  correspondingly  shorter  posterior  tegumentary  flap, 
or  flaps  which  include  all  the  muscle  down  to  the  bone  as  well  as  the 
skin  may  be  used. 

Surgical  Anatomy  of  the  Hip-joint. — The  hip-joint  is  composed 
of  the  upper  end  of  the  femur  and  the  acetabular  cavity  of  the  os 
innominatum. 

The  upper  end  of  the  femur  presents  a  rounded  head  which 
represents  about  two-thirds  of  a  sphere;  it  is  smooth,  covered  with 
cartilage,  and  is  marked  in  the  apex  of  its  posterior,  inferior  quad- 
rant by  a  depression  in  which  is  attached  the  ligamentum  teres.  The 
head  of  the  femur  is  directed  upward,  inward,  and  forward. 

The  head  of  the  femur  is  joined  to  the  shaft  by  the  neck,  which 
passes  from  the  head  downward  and  outward  to  the  shaft;  the  neck 
is  somewhat  flattened  from  before  backward,  and  is  broader  at  its 
junction  with  the  shaft  than  with  the  head,  and  is  narrowest  mid- 
way between  these  points. 

The  upper  end  of  the  shaft  presents  upon  its  outer  aspect  the 
great  trochanter,  a  prominent,  square-shaped  mass  of  bone.  The 
external  surface  of  the  great  trochanter  is  continuous  with  the  ex- 
ternal surface  of  the  shaft,  and  is  marked  by  a  rough  line  that  passes 
obliquely  from  above  downward  and  forward;  to  this  line  is  attached 
the  gluteus  medius  muscle;  the  smooth  surface  below  and  behind 
this  line  is  covered  by  the  gluteus  maximus,  a  bursa  being  inter- 
posed. 

The  inner  surface  of  the  trochanter  is  applied  to  the  shaft  of 
the  bone,  except  for  its  upper,  posterior  part,  which  is  free  and 
hollowed  out  to  form  the  digital  fossa;  here  the  tendon  of  the 
obturator  externus  is  attached,  and  this  attachment  must  be  sepa- 
rated before  one  can  dislocate  the  head  of  the  femur  backward  in 
doing  a  resecti®n  of  the  hip-joint. 

The  prominent  upper  border  of  the  great  trochanter  is  free, 
and  gives  attachment  to  the  tendons  of  the  obturator  internus  and 
gemelli  in  front  and  to  the  tendon  of  the  pyriformis  behind.  The 
anterior  border  of  the  trochanter  major  gives  attachment  to  the 


524  LOWER  EXTREMITY. 

gluteus  minimus;  its  posterior  border  is  thick  and  rounded  and 
limits  the  digital  fossa  behind. 

On  the  inner  side  of  the  shaft,  at  its  junction  with  the  neck, 
is  the  trochanter  minor;  it  is  smaller  than  the  trochanter  major, 
prominent,  and  pyramidal;  to  it  and  to  the  shaft  of  the  bone  imme- 
diately below  it  is  attached  the  ilio-psoas  muscle. 

Upon  the  front  of  the  bone,  commencing  above  and  externally 
at  the  great  trochanter  and  curving  obliquely  downward  and  inward 
and  passing  around  the  inner  side  of  the  shaft,  just  below  the  lesser 
tuberosity,  is  the  so-called  spiral  line.  This  line,  on  the  back  of  the 
bone,  runs  into  the  linea  aspera,  forming  one  of  the  arms  of  this 
prominent  ridge.  This  spiral  line  is  well  marked,  and  upon  the  front 
of  the  bone  gives  attachment  to  the  capsular  ligament. 

Upon  the  posterior  aspect  of  the  bone,  a  prominent,  rounded 
line  is  presented,  which  runs  from  the  posterior  border  of  the  great 
trochanter  downward  and  inward  to  the  lesser  trochanter;  this  is 
known  as  the  posterior  intertrochanteric  line. 

The  acetabulum  is  a  large  cup-shaped  depression  corresponding 
to  the  junction  of  the  three  portions  (pubes,  ilium,  ischium)  of  which 
the  os  innominatum  is  formed.  This  cavity  extends  downward  and 
inward  as  far  as  the  edge  of  the  obturator  foramen,  and  its  floor 
looks  downward,  outward,  and  forward;  it  is  surrounded  by  a  sharp, 
prominent  ridge  whose  summit  gives  attachment  to  the  ring-like 
cotyloid  fibro-cartilage  which  serves  to  deepen  the  cavity,  constrict- 
ing its  orifice  and  gripping  the  head  of  the  femur,  thus  assisting  in 
retaining  it  within  the  socket  of  the  joint.  In  order  to  dislocate  the 
head  of  the  bone,  in  resecting  the  hip-joint,  it  is  necessary  to  nick 
this  cotyloid  ligament. 

The  lower  portion  of  the  margin  or  rim  of  the  acetabulum,  that 
part  which  is  adjacent  to  the  obturator  foramen,  is  interrupted  by 
a  wide,  deep  notch,  the  cotyloid  notch.  In  the  recent  state  this 
notch  is  bridged  over  by  a  ligamentous  band,  the  transverse  liga- 
ment; that  part  of  the  ring-like  cotyloid  fibro-cartilage  which  corre- 
sponds to  the  notch  is  applied  to  the  upper  surface  of  the  transverse 
ligament.  The  transverse  ligament  converts  the  cotyloid  notch  into 
a  foramen,  through  which  vessels,  nerves,  etc.,  pass  into  the  hip- 
joint. 

The  floor  of  the  acetabulum  is  partly  articular  and  partly  non- 
articular;  the  articular  part  is  the  smooth,  horseshoe-shaped  surface 
which  occupies  the  periphery  of  the  cavity;  the  non-articular  portion 


AMPUTATIONS,  RESECTIONS,  ETC.  525 

is  the  rough,  depressed  area  which  occupies  the  middle  of  the  cavity 
and  is  prolonged  down  along  the  floor  to  the  site  of  cotyloid  notch; 
this  non-articular,  depressed  surface  lodges  a  mass  of  fat  and  its 
margins  give  attachment  to  the  ligamentum  teres. 

The  hip-joint  is  provided  with  a  capsular  ligament,  which  is 
attached  above  around  the  margin  of  the  acetabulum  and  transverse 
ligament  (which  completes  the  circumference  of  the  acetabulum  be- 
low); below  it  is  attached  to  the  femur;  in  front,  to  the  spiral  line 
as  far  as  the  lesser  trochanter;  behind  it  is  attached  to  the  surface 
of  the  neck  proper,  one-half  to  two-thirds  inch  above,  away  from, 
the  posterior  intertrochanteric  line.  The  capsule  is  materially 
strengthened  by  the  circular  fibers  that  are  woven  into  it  (ligament 
of  Webber). 

The  capsule  is  reinforced  by  three  auxiliary  bands  of  fibers. 
The  most  important  is  the  ilio-femoral  band,  which  is  thickest, 
widest,  and  longest;  it  is  attached  above  to  the  ilium  just  below  and 
behind  the  anterior  inferior  spinous  process  and  below  spreads  out 
and  is  attached  along  the  spiral  line,  from  the  greater  to  the  lesser 
trochanter;   it  is  known  as  the  "Y"  ligament  of  Bigelow. 

The  ischio-femoral  band  is  attached  to  the  ischium  behind  and 
below  the  acetabulum  (to  the  upper  part  of  the  groove  for  the  tendon 
of  the  obturator  externus),  and  to  the  femur  it  is  attached  at  the 
upper  part  of  the  trochanter  major  and  spreads  out  and  encircles 
the  capsule. 

The  pectineo-  or  pubo-  femoral  band  is  thin,  and  attached  to 
the  pectineal  eminence  on  the  os  innominatum  and  to  the  neck  of 
the  femur  behind  the  ilio-femoral  baud,  being  incorporated  with  the 
lowermost  fibers  of  the  ilio-femoral  band. 

The  transverse  ligament  is  a  fibrous  band  that  bridges  across  the 
notch  in  the  lower  part  of  the  rim  of  the  acetabulum,  thus  convert- 
ing the  cotyloid  notch  into  a  foramen. 

The  cotyloid  ligament  is  a  complete  fibro-cartilaginous  ring 
which  is  attached  to  the  edge  of  the  bony  rim  and  the  transverse 
ligament,  encircling  the  acetabulum  and  deepening  the  cavity  and 
constricting  its  orifice. 

The  ligamentum  teres  is  an  interarticular  fibrous  band  which 
passes  between  the  head  of  the  femur  and  the  bottom  of  the  acetab- 
ulum. It  is  attached  in  the  bottom  of  the  acetabulum  to  the  mar- 
gins of  the  rough  space  and  to  the  transverse  ligament;  its  narrow 
end  is  attached  to  a  dimple  which  marks  the  apex  of  the  posterior 


526  LOWER  EXTREMITY. 

inferior  quadrant  of  the  head  of  the  femur.  It  is  usually  a  strong 
band. 

The  rough  depression  in  the  bottom  of  the  acetabular  cavity  is 
filled  in  with  a  cushion  of  fat  in  which  the  vessels  that  pass  along 
the  ligamentum  teres  to  supply  the  head  of  the  bone  are  lodged. 

The  synovial  membrane  of  the  hip-joint  lines  the  inner  surface 
of  the  capsule,  covers  the  mass  of  fat  in  the  floor  of  the  acetabular 
cavity,  and  is  thence  reflected  upon  the  ligamentum  teres  as  far  as 
the  head  of  the  femur  as  a  tubular  prolongation,  and  thus  practically 
shuts  the  teres  ligament  out  of  the  cavity  of  the  joint. 

A  large  bursa  lies  beneath  the  ilio-psoas  muscle  upon  the  front 
of  the  capsule;  this  often  communicates  with  the  joint.  Smaller 
bursas  are  located  between  the  various  tendons  and  adjoining  bony 
parts,  etc. 

The  hip-joint  is  covered  in  front  by  the  ilio-psoas  and  the  pectin- 
eus  muscles;  on  the  outer  side  by  the  glutei;  behind  by  the  gluteus 
maximus,  pyriformis,  obturator  internus  and  gemelli,  and  quadratus 
femoris;   internally  and  below  by  the  obturator  externus. 

EXARTICULATION  OF  THE  THIGH  AT  THE  HlP- JOINT  (WTETH). — 

The  patient  lies  upon  the  back  with  the  thigh  extended  over  the  end  of 
the  table.  In  order  to  prevent  slipping  of  the  tourniquet,  which  is 
placed  about  the  thigh  for  the  purpose  of  compressing  the  femoral 
vessels  and  thus  controlling  the  hemorrhage,  two  long  pins  are  in- 
troduced through  the  soft  parts,  the  ligature  being  applied  above 
these.  The  pins  are  about  ten  inches  long  and  are  introduced  as 
follows: — 

One,  transfixing  the  soft  parts  on  the  outer  side  of  the  thigh, 
is  introduced  one  inch  below  the  anterior  superior  spine  of  the  ilium, 
and,  passing  backward  through  the  soft  parts  for  a  distance  of  about 
three  inches,  emerges  about  one  inch  below  the  crest  of  the  ilium; 
this  pin  transfixes  the  upper  part  of  the  tensor  vaginas  femoris 
muscle. 

A  second  pin  is  introduced  through  the  soft  parts  on  the  inner 
side  of  the  thigh,  one  inch  below  the  pubic  bone;  it  passes  through 
the  adductor  muscles,  and  emerges  posteriorly  one  inch  below  the 
tuberosity  of  the  ischium;  in  introducing  this  inner  pin  one  must 
avoid  injuring  the  femoral  vein.  The  femoral  artery  passes  into  the 
thigh  underneath  Poupart's  ligament  at  a  point  which  corresponds 
to  the  middle  of  a  line  drawn  from  the  anterior  superior  iliac  spine  to 
the  pubic  spine.     The  femoral  vein  lies  just  to  the  inner  side  of  the 


AMPUTATIONS,  RESECTIONS,  ETC. 


527 


artery.    Corks  are  applied  to  the  sharp  points  of  the  pins  after  they 
have  heen  introduced  to  prevent  one's  pricking  one's  self. 

The  tourniquet  is  placed  around  the  thigh  ahove  the  pins,  which 
prevent  its  slipping  down.    A  pad  may  he  placed  heneath  the  tourni- 


Fig.  216. — Exarticulation  at  Hip-joint.  Wyeth  pins  in  place  to  prevent 
ligature  from  slipping.  Upon  the  outer  side  of  thigh  the  incision  reaches  to 
the  bone.  A  circular  skin  flap  has  been  turned  back  and  the  muscles  and 
blood-vessels  divided  down  to  the  bone.  Clamps  applied  to  femoral  artery 
and  vein. 


quet,  upon  the  front  of  the  thigh,  corresponding  to  the  location  of 
the  femoral  vessels,  to  still  further  secure  their  compression. 

The  operator  stands  on  the  outer  side  of  the  limb,  which  is 
supported  by  an  assistant.  With  a  long  knife  a  circular  incision  is 
made  through  the  skin  and  fat  down  to  the  deep  fascia;    this  in- 


528  LOWER  EXTREMITY. 

cision  should  encircle  the  thigh  a  hand's  breadth  (five  inches)  below 
the  perineum. 

With  a  stout  scalpel  a  second  incision  is  made  along  the  outer 
side  of  the  thigh.  Commencing  above  the  great  trochanter,  this  in- 
cision is  carried  downward,  upon  the  surface  of  the  trochanter  and 
along  the  outer  side  of  the  thigh,  as  far  as  the  circular  incision, 
where  it  terminates.  This  second  incision  should  reach  to  the  bone 
throughout  its  entire  extent. 

The  edge  of  the  skin  flap  which  is  marked  out  by  the  circular  in- 
cision is  seized  and  dissected  away  from  the  deep  fascia  for  a  distance 
of  about  three  inches.  At  this  point,  the  skin  flap  being  retracted,  a 
circular  cut  is  made  with  the  long  knife,  through  the  muscles,  down 
to  the  bone,  dividing  the  vessels,  the  femoral  and  the  profunda  femoris, 
which  lie  in  front  and  internal  to  the  bone.  These  vessels  are  now 
sought,  clamped,  and  tied.  In  order  to  get  better  access  to  the  vessels 
the  muscles  may  be  scraped  downward  away  from  the  shaft  of  the 
bone  for  a  short  distance.  We  should  make  sure  of  the  femoral  artery 
and  vein  and  the  profunda  femoris  and  its  vein;  these  latter  lie  in  a 
deeper  plane  than  the  femoral  vessels.  Any  other  vessels  which  may 
be  visible,  searching  in  the  spaces  between  the  bundles  of  muscle,  are 
also  ligated. 

The  tourniquet  may  now  be  removed,  gradually  loosening  it  and 
catching  additional  vessels  as  they  bleed,  and  then  the  pins  are  with- 
drawn or  the  tourniquet  and  pins  may  be  left  until  after  the  bone  has 
been  enucleated  and  the  amputation  is  complete,  but  in  all  cases  the 
main  vessels  should  always  be  secured  immediately  after  the  circular 
cut  through  the  muscles  has  been  made. 

The  next  step  in  the  operation  is  the  separation  of  the  soft  parts 
from  the  shaft  of  the  bone  and  the  dislocation  of  the  head  of  the  bone 
from  its  socket.  The  soft  parts  are  retracted  and  stripped  away  from 
the  bone,  working  with  the  edge  of  the  knife  close  to  the  bone  and 
rotating  the  limb  first  inward  and  then  outward  to  facilitate  this  part 
of  the  operation.  After  the  shaft  of  the  bone  has  been  denuded  of  its 
soft  parts  up  as  far  as  the  capsule  of  the  joint,  the  joint  is  opened  by 
incising  the  capsule  and  the  cotyloid  fibro-cartilage,  and  the  head  of 
the  bone  is  then  thrown  out  of  its  socket,  cutting  or  tearing  the  liga- 
mentum  teres,  and  any  remaining  soft  parts,  and  thus  completing  the 
exarticulation. 

After  ligating  any  bleeding  points  that  show  themselves  and 
bavin?  cut  the  nerves  short,  the  edges  of  the  skin  are  united  with  in- 


AMPUTATIONS,  RESECTIONS,  ETC.  529 

terrupted  catgut  or  silk-worm  gut  sutures,  taking,  besides,  a  few  deep 
catgut  sutures  through  the  muscle.  A  large  drainage  tube  is  intro- 
duced; this  reaches  into  the  deepest  part  of  the  wound,  into  the 
acetabular  cavity,  and  emerges  through  the  lower  end  of  the  in- 
cision. 

ExARTICULATION  AT  THE  HlP-JOINT,  WITH  PRELIMINARY  LIGA- 
TION of  the  Common  Femoral. — Amputation  at  the  hip-joint  may  be 
accomplished  with  the  loss  of  very  little  blood  if,  as  a  preliminary  step, 
the  common  femoral  artery  and  vein  have  been  ligated  high  up  within 
two  inches  of  Poupart's  ligament;  i.e.,  above  the  origin  of  the  pro- 
funda femoris  branch.  After  the  common  femoral  artery  and  vein 
have  been  tied  a  circular  incision  is  made  around  the  thigh,  five  inches 
below  the  perineum,  and  in  addition  to  this  a  longitudinal  incision, 
which  commences  above  the  trochantar  major  and  is  carried  down 
the  outer  side  of  the  thigh  just  the  same  as  in  the  preceding  opera- 
tion. The  integument  is  then  reflected,  in  the  shape  of  a  tegumentary 
cuff,  for  a  distance  of  about  three  inches,  at  which  level  the  muscles 
are  divided  layer  by  layer,  ligating  any  vessels  that  bleed  as  they  are 
met  with.  In  cutting  through  the  muscles  on  the  back  of  the  thigh 
we  meet  several  large  branches,  but  these  are  readily  secured  with 
clamps  as  they  spurt  and  are  then  ligated.  Having  cut  through  the 
muscles  down  to  the  bone,  the  soft  parts  are  separated  from  this  in  the 
usual  manner,  and  the  head  of  the  bone  turned  out  of  the  acetabulum 
and  the  amputation  thus  completed.  We  may  use  this  method  where 
tumor,  etc.,  prevent  the  use  of  the  Wyeth  pins. 

Resections.  Ankle-joint  (Langenbeck-Htjeter). — This  opera- 
tion is  done  subperiosteally,  and  is  especially  applicable  to  cases  of 
traumatism.  The  foot  rests  with  its  inner  side  upon  a  thin  sand  bag, 
the  knee  being  slightly  flexed. 

An  incision  about  three  inches  long  is  made  along  the  posterior 
border  of  the  fibula  just  in  front  of  the  sheath  of  the  peronei  tendons; 
this  is  carried  downward  as  far  as  the  tip  of  the  malleolus,  where  it  is 
turned  upward  for  a  short  distance  along  the  front  border  of  this  mal- 
leolus. This  incision  reaches  through  the  soft  parts  and  periosteum 
to  the  bone.  The  tissues  which  cover  the  bone  are  raised  subperioste- 
ally with  an  elevator,  laying  bare  all  of  the  lower  end  of  the  fibula  and 
taking  care  not  to  injure  the  peronei  tendons,  which  are  lodged  in  the 
groove  upon  the  posterior  border  of  the  external  malleolus.  There  is 
considerable  difficulty  in  separating  the  periosteum  from  the  surface 
of  the  malleolus  below,  and  in  order  to  accomplish  this  it  may  be  neces- 


530 


LOWER  EXTREMITY. 


sary  to  resort  to  the  knife,  cutting  with  its  edge  close  upon  the  sur- 
face of  the  bone  or  else  one  may  chisel  away  a  thin  shell  of  the  cortex 
of  the  bone. 


Fig.  217.— Right  Foot,   Outer  Side.     External  incision  for  resection 
of  ankle  (Langenbeck-Hueter). 


Fig.   218.— Right  Foot,   Inner  Side.     Anchor-shaped  incision  upon  inner 
side    of   ankle    for   resection       (Lnngenbeck-Hueter). 

In  isolating  the  lower  end  of  the  fibula  on  its  inner  aspect,  corre- 
sponding to  the  attachment  of  the  interosseous  ligament  which  binds 


AMPUTATIONS,  RESECTIONS,  ETC.  531 

the  lower  ends  of  the  tibia  and  fibula  together,  care  should  be  taken 
to  stick  close  to  the  surface  of  the  bone,  so  as  to  leave  the  periosteum 
connected  with  the  interosseous  ligament. 

Now,  corresponding  to  the  upper  part  of  the  wound,  the  fibula  is 
encircled  with  a  chain  or  wire  saw  and  divided,  or  it  may  be  cut 
through  with  a  chisel.  The  upper  end  of  the  detached  fragment  is 
then  seized  with  the  bone  forceps  and  wrenched  free  from  the  remain- 
ing ligaments  (external  lateral)  which  still  hold  it.  This  gives  access 
to  the  interior  of  the  joint,  and  through  this  opening  the  upper  artic- 
ular surface  of  the  astragalus  may  be  removed  with  the  chisel  or  sharp 
spoon  and  the  joint  irrigated  and  drained. 

One  may  stop  with  this  partial  operation,  or  else  proceed  to 
do  a  complete  resection.  In  this  latter  case  the  foot  is  turned  so 
that  it  rests  upon  its  outer  side,  and  an  anchor-shaped  incision  then 
made  which  consists  of  a  cut  two  and  one-half  or  three  inches  long, 
down  the  middle  of  the  inner  subcutaneous  surface  of  the  tibia  as 
far  as  the  tip  of  the  malleolus,  and  from  this  point  additional  incisions, 
which  are  carried  upward  along  the  anterior  and  posterior  borders  of 
the  malleolus  for  a  distance  of  about  one  inch.  These  incisions  all 
reach  through  the  periosteum  to  the  bone.  In  many  cases  the  single 
longitudinal  incision  will  suffice.  Through  this  incision  the  peri- 
osteum and  soft  parts  are  separated  from  the  lower  end  of  the  tibia 
in  one  mass,  working  first  upon  the  anterior  surface  and  then  upon 
the  posterior  surface  of  the  bone,  and  avoiding  injury  to  the  tendons; 
upon  the  outer  surface  of  the  lower  end  of  the  tibia,  corresponding 
to  the  attachment  of  the  tibio-fibular  interosseous  ligament,  one 
should  work  as  close  as  possible  to  the  surface  of  the  bone. 

During  this  part  of  the  operation  the  edges  of  the  wound  are 
held  well  apart  with  blunt  retractors.  The  soft  parts  should  be 
separated  from  the  lower  end  of  the  bone  as  much  as  possible  with 
the  sharp-edged  periosteum  elevator,  but,  if  necessary,  one  may 
resort  to  the  use  of  the  knife,  keeping  close  to  the  surface  of  the 
bone,  or  may  chisel  away  a  thin  layer  of  the  cortex  of  the  bone. 
Finally,  the  internal  lateral  (deltoid)  ligaments  are  cut  close  to  the 
edge  of  the  malleolus, — it  is  better  to  separate  these  also  with  the 
elevator  or  the  chisel, — and  the  ankle-joint  is  now  open  upon  its 
inner  side.  The  lower  end  of  the  tibia  may  be  cut  through  with 
the  chain  or  wire  saw  or  chisel  upon  the  same  level  as  the  fibula  was 
divided;  it  is  then  seized  with  a  bone  forceps  and  detached  from  any 
remaining;  bands  that  hold  it. 


532  LOWER  EXTREMITY. 

The  upper  articular  surface  of  the  astragalus,  if  desirable,  may 
now  he  sawn  off  from  hehind  forward  with  a  thin,  flat  saw,  taking 
care  of  the  tendons  on  the  hack  and  front  of  the  joint,  or,  better, 
it  may  be  cut  away  with  the  chisel.  This  section  should  be  made 
through  such  a  plane  that,  when  the  sawn  surface  of  the  astragalus 
is  apposed  to  the  sawn  surface  of  the  tibia,  the  foot  will  be  at  right 
angles  to  the  leg.  There  is  a  tendency  to  make  the  section  through 
the  astragalus  upon  a  plane  which  would  place  the  foot  in  a  position 
of  extension  (plantar  flexion),  and  this  is  to  be  avoided. 

When  this  operation  is  performed  for  traumatism,  the  result  is 
good.  Much  of  the  bone  is  reproduced  and  the  parts  regain  almost 
their  former  contour;  any  excess  of  bone  that  is  produced  from  the 
detached  periosteum  is  usually  absorbed.  Portions  of  the  tibia,  even 
as  much  as  8  to  10  cm.,  have  been  removed  and  reproduced.  An 
ankylosed  ankle  is  the  preferable  result  after  this  operation;  the 
joints  between  the  bones  of  the  tarsus  eventually  give  considerable 
spring  to  the  foot.  When  the  operation  is  performed  for  tuber- 
culosis, frequently  no  bone  is  reproduced,  healing  fails,  and  we  have, 
as  a  result,  a  wabbly  joint,  with  sinuses. 

It  may  not  be  necessary  in  all  cases  to  do  a  complete  resection, 
since  all  of  the  parts — for  example,  the  articular  surface  of  the 
astragalus — may  not  be  diseased,  etc.  Care  should  be  exercised  in 
applying  the  dressings  to  place  the  foot  at  a  right  angle  with  the  leg 
and  turned  somewhat  outward.  It  is  probably  wise  in  all  cases  to 
drain,  at  least  for  a  few  days.  The  edges  of  the  wound  are  approxi- 
mated with  interrupted  catgut  sutures. 

With  Extirpation  of  the  Entire  Astragalus. — The  long  middle  in- 
cision on  the  inner  side  of  the  ankle  is  prolonged  downward  about  one 
inch  farther  than  described  in  the  foregoing  operation,  so  as  to  reach  to 
the  sustentaculum  tali,  and  at  its  lower  end  an  antero-posterior  incision 
is  added  which  is  about  two  inches  long  and  which  penetrates  to  the 
bone  (see  Fig.  222).  The  soft  parts  are  separated  forcibly  with  the 
elevator  and  the  whole  of  the  astragalus  thus  brought  into  view. 
The  joint  between  the  head  of  the  astragalus  and  the  scaphoid  is 
opened  (tuberosity  of  the  scaphoid  is  the  guide),  and  also  the  joint 
between  the  astragalus  and  the  os  calcis  (sustentaculum  tali);  after 
this  the  astragalus  is  seized  with  a  bone  forceps,  and,  twisting  and 
at  the  same  time  cutting  close  to  the  bone,  it  is  removed.  In  re- 
secting the  ankle-joint  for  tuberculosis,  if  the  astragalus  is  diseased, 
it  is  well  to  remove  this  bone  entire. 


AMPUTATIONS,  RESECTIONS,  ETC. 


533 


Ankle-joint  (Koenig). — This  is  a  satisfactory  operation,  espe- 
cially for  tuberculous  joints.  The  lower  part  of  the  leg  rests  upon  a 
sand  hag,  the  foot  being  elevated  and  turned  outward.  An  incision  is 
made  upon  the  inner  side  of  the  ankle,  commencing  an  inch  or  an  inch 
and  one-half  above  the  level  of  the  joint,  and  passing  down  along  the 
anterior  border  of  the  tibia  and  inner  malleolus  parallel  with  and  just 
internal  to  the  extensor  tendons  which  lie  upon  the  front  of  the  joint. 


MP 


Fig.  219. — K,  incisions  for  resection  of  ankle  (Koenig);  M.P.,  articula- 
tion between  metacarpal  bone  of  the  big  toe  and  first  phalanx;  8,  location 
of  tubercle  of  scaphoid.  Incision  for  amputation  of  big  toe  with  removal  of 
the  first  metatarsal. 

This  incision  penetrates  through  the  integument  and  periosteum  to 
the  tibia,  and  is  continued  downward  across  the  ankle-joint,  into  which 
it  opens,  and  then  curves  forward  upon  the  neck  of  the  astragalus  as 
far  as  the  tubercle  of  the  scaphoid. 

A  similar  incision  is  made  upon  the  outer  side  of  the  joint, 
commencing  above  at  the  same  level  as  the  internal  incision  and 
passing  downward  along  the  anterior  edge  of  the  outer  malleolus, 
across  the  ankle-joint,  into  which  it  opens,  and  ending  at  a  point 


534  LOWER  EXTREMITY. 

opposite  the  lower  end  of  the  inner  incision.  This  incision  runs 
parallel  with  the  outer  margin  of  the  extensor  group  of  tendons. 

Between  these  two  incisions  there  is  a  bridge  of  tissues  consist- 
ing of  integument,  anterior  tibial  vessels  and  nerve,  extensor  ten- 
dons, anterior  ligament,  and  synovial  membrane.  This  mass  of  soft 
parts  is  freely  separated  from  the  front  of  the  tibia  above  and  from 
the  astragalus  below,  as  much  as  possible  subperiosteally  with  the 
elevator,  and  when  necessary  with  occasional  snips  with  the  scissors 
or  knife. 

Access  to  the  ankle-joint  is  now  fairly  free,  and  one  may  com- 
mence the  excision  of  the  diseased  synovial  membrane  with  mouse- 
toothed  forceps  and  scissors;  the  ends  of  the  tibia  and  fibula  and 
the  articular  surface  of  the  astragalus  may  also  be  reached  with  the 
sharp  spoon. 

If  it  is  desirable  to  resect  the  ends  of  the  bones  and  it  becomes 
necessary  to  gain  still  better  access  to  the  interior  of  the  joint,  a 
thin  shell  of  the  cortex,  carrying  the  periosteum  and  the  attach- 
ments of  the  ligaments,  may  be  chiseled  away  from  the  surface  of  the 
inner  and  also  from  the  surface  of  the  outer  malleolus,  leaving  them 
bare  and  free.  Drawing  the  soft  parts  widely  asunder  with  blunt 
hooks,  a  broad  chisel  may  be  applied,  through  the  inner  incision,  to 
the  lower  end  of  the  tibia,  and  this  may  then  be  divided;  the  frag- 
ment which  is  thus  detached  is  seized  with  bone  forceps  and  re- 
moved, cutting  the  remaining  attachments  close  to  the  bone  and 
taking  care  not  to  injure  the  tendons  which  lie  close  to  the  back  of 
the  bone  nor  the  posterior  tibial  vessels  and  nerve.  The  lower,  bare 
end  of  the  fibula  may  be  treated  in  a  similar  manner,  avoiding  the 
peroneal  tendons  in  the  groove  upon  its  posterior  surface.  In  laying 
bare  the  malleoli  one  should  try  to  separate  the  lateral  ligaments 
with  the  chisel  subperiosteally  in  preference  to  cutting  them. 

The  articular  surface  of  the  astragalus  may  be  removed  with  the 
broad  chisel  or  with  a  narrow,  thin-bladed  saw,  the  section  being 
made  through  a  plane  which  will  allow  the  foot  to  be  placed  at  a 
right  angle  with  the  leg. 

In  most  cases  of  tuberculous  joints  when  the  astragalus  is  in- 
volved, it  is  probably  better  to  remove  this  bone  entire;  this  will 
also  permit  treatment  of  the  joints  between  the  astragalus  and 
os  calcis  and  the  astragalus  and  scaphoid  if  these  are  involved,  and  this 
is  frequently  the  case.  The  astragalus  is  readily  removed  through  the 
inner  incision,  first  opening  the  joint  between  the  head  of  the  astrag- 


AMPUTATIONS,  RESECTIONS,  ETC.  535 

alus  and  the  scaphoid,  and  then  the  joint  between  the  head  of  the 
astragalus  and  the  sustentaculum  tali  of  the  os  calcis.  The  astragalus 
is  seized  with  a  lion-tooth  forceps,  and,  cutting  its  attachments  close 
to  the  bone,  it  is  twisted  free. 

Whether  the  entire  astragalus  is  removed  or  not  in  cases  of 
tuberculosis  the  whole  synovial  membrane  lining  of  the  ankle-joint 
should  be  removed  with  toothed  forceps  and  scissors;  that  part  of 
the  membrane  which  lines  the  posterior  portion  of  the  capsule  is 
difficult  to  reach,  but  its  removal  may  be  facilitated  by  drawing  the 
foot  strongly  downward  away  from  the  tibia  and  at  the  same  time 
strongly  reflecting  the  anterior  flap  or  bridge  of  soft  parts. 

Usually  there  are  no  vessels  to  tie.  Drainage  tubes  may  be  in- 
troduced on  each  side  and  the  wound  packed  with  iodoform  gauze. 
The  edges  of  the  wounds  are  brought  together  with  interrupted  catgut 
sutures,  being  left  partly  open  to  allow  for  the  drainage  tubes  and 
gauze.    The  foot  is  dressed  at  a  right  angle  to  the  leg. 

Ankle-joint  (Lauenstein). — A  very  satisfactory  method,  espe- 
cially for  tuberculous  joints.  The  knee  is  slightly  flexed,  and  the 
foot  rests  with  its  inner  surface  upon  a  thin  sand  bag.  The  in- 
cision is  placed  upon  the  outer  side  of  the  joint,  passing  through  the 
skin  and  subcutaneous  fat  and  exposing  the  external  surface  of  the 
outer  malleolus  and  the  lower  end  of  the  fibula  for  a  distance  of  about 
three  inches.  The  surface  of  the  fibula  thus  exposed  is  subcutaneous, 
and  is  included  between  the  tendon  of  the  peroneus  tertius  in  front 
and  the  tendon  of  the  peroneus  brevis  behind;  from  the  tip  of  the 
outer  malleolus  the  incision  curves  forward  and  inward  across  the  dor- 
sum of  the  foot,  terminating  just  external  to  the  tendon  of  the  pero- 
neus tertius,  which  should  not  be  cut. 

The  joint  is  now  opened  in  front  of  the  external  malleolus  by 
cutting  the  anterior  fasciculus  of  the  external  lateral  ligament,  and 
then  the  integument,  together  with  the  extensor  tendons  and  other 
soft  parts,  including  the  anterior  portion  of  the  capsular  ligament, 
are  separated  from  the  front  of  the  tibia  with  the  periosteum  elevator, 
these  soft  parts  being  meanwhile  drawn  forcibly  forward,  away  from 
the  front  surface  of  the  tibia,  with  a  blunt  hook. 

The  posterior  margin  of  the  incision  is  next  seized  and  retracted 
and  the  sheath  of  the  peroneal  tendons  opened;  these  tendons,  to- 
gether with  the  integument,  are  drawn  well  back  out  of  the  way  with 
a  blunt  hook  and  the  remaining  fasciculi  of  the  external  lateral  liga- 
ment (middle  and  posterior)  then  divided. 


536 


LOWER  EXTREMITY. 


The  foot,  being  somewhat  extended  in  order  to  relieve  the  ten- 
sion of  the  peronei  tendons,  may  now,  with  moderate  force,  be  com- 
pletely dislocated  by  rotating  it  inward  upon  its  long  axis  in  a  hinge- 
like fashion  around  the  internal  malleolus. 

All  parts  of  the  joint  are  now  accessible;  the  synovial  membrane 
may  be  dissected  away  with  a  thumb  forceps  and  scissors,  and  the 
upper  articular  surface  of  the  astragalus,  if  desired,  may  be  chiseled 
away  or  resected  with  a  thin,  flat  saw,  or,  by  extending  the  incision 
somewhat,  the  entire  bone  may  be  removed.  If  the  tibia  and  fibula 
are  diseased,  the  soft  parts  about  the  lower  ends  of  these  bones  may 
be  detached,  preferably  subperiosteally,  with  the  elevator,  and  the  dis- 
eased portion  of  the  bones  then  resected  with  the  saw.    If  the  articular 


Fig.  220.— Resection  of  Ankle-joint.     Lauenstein's  incision. 

surface  only  of  the  astragalus,  and  not  the  whole  bone,  is  to  be  re- 
moved, one  should  take  care  to  make  the  section  through  the  bone  in 
such  a  plane  that,  when  the  foot  is  replaced,  the  cut  surfaces  of  the 
astragalus  and  tibia  will  permit  of  the  foot  being  placed  at  a  right 
angle  with  the  leg.  There  is  a  marked  tendency,  in  resecting  the 
articular  surface  of  the  astragalus,  to  carry  the  section  through  a  plane 
which  would  result  in  the  foot's  being  joined  to  the  leg  at  an  obtuse 
angle,  in  a  position  of  extension,  and  this  is  to  be  avoided. 

Ankle-joint,  Osteoplastic  (Mikulicz-Wladimieow).  —  The 
patient  lies  upon  the  abdomen.  A  transverse  incision  is  made 
across  the  sole  of  the  foot.  This  incision  commences  on  the  outer 
border  of  the  foot  a  finger's  breadth  behind  the  tuberosity  which 


AMPUTATIONS,  RESECTIONS,  ETC. 


537 


marks  the  base  of  the  fifth  metatarsal  bone  (little  toe),  and  ends 
on  the  inner  side  of  the  foot  at  the  tubercle  of  the  scaphoid.  From 
either  end  of  this  incision,  upon  either  side  of  the  foot  an  additional 
incision  is  carried  obliquely  upward  and  backward  across  the  lower  end 
of  each  malleolus  to  their  posterior  borders,  and  then  still  another 
incision  is  made  transversely,  just  above  the  heel,  uniting  the  ends  of 
the  two  lateral  incisions  and  dividing  the  tendo  Achillis  and  the  poste- 
rior tibial  vessels.  All  these  incisions  penetrate  to  the  bone.  The  foot 
is  now  forcibly  flexed  (dorsal  flexion)  and  the  ankle-joint  is  opened 
from  behind  and  the  lateral  ligaments  are  cut.     The  astragalus  and 


Fig.  221. — Right  Foot,  Inner  Side.  Line  of  incision  for  Mikulicz-Wladiml- 
row  osteoplastic  resection  of  the  ankle-joint.  Dotted  lines  indicate  section 
through  the  bones. 


the  os  calcis  are  then  dissected  out  of  the  mass  of  soft  parts  in  which 
they  are  located,  working  with  the  edge  of  the  knife  close  to  the  sur- 
face of  the  bones;  during  this  step  of  the  operation  the  bones  are 
forcibly  drawn,  first  to  one  side  and  then  to  the  other,  in  order  to 
facilitate  their  enucleation,  and,  working  forward,  the  joint  between 
the  astragalus  and  the  os  calcis  behind  and  the  scaphoid  and  cuboid  in 
front  is  finally  opened.  The  remaining  ligaments  and  bands  are  then 
severed  and  the  bones  removed. 

The  soft  parts  around  the  lower  end  of  the  tibia  aud  fibula  are 
now  separated,  cutting  with  the  edge  of  the  knife  close  to  the  surface 


538  LOWER  EXTREMITY. 

of  the  bones,  and  a  thin  slice  of  the  lower  end  of  the  tibia,  including 
both  malleoli,  is  sawn  off. 

A  thin  slice,  including  the  articular  surfaces,  is  likewise  sawn 
off  from  the  scaphoid  and  cuboid,  so  that  when  the  foot  is  extended 
(plantar  flexion)  the  sawn  surfaces  of  the  cuboid  and  scaphoid  may 
be  apposed  to  the  sawn  surfaces  of  the  tibia  and  fibula,  the  long  axis 
of  the  leg  being  thus  prolonged  into  the  foot,  as  a  direct  line,  the 
patient  walking  upon  the  heads  of  the  metatarsal  bones  and  the 
phalanges. 

The  posterior  tibial  vessels  which  lie  behind  the  ankle-joint, 
to  the  inner  side  of  the  tendo  Achillis,  are  cut,  and  must  be  ligated. 
The  bones  may  be  retained  in  contact  with  sutures  of  chromicized 
catgut  carried  through  drill  holes,  but  this  is,  as  a  rule,  unnecessary, 
especially  if  the  foot  is  put  up  in  plaster.  The  skin  wound  is  closed 
with  interrupted  catgut  sutures. 

One  should  be  careful  that  the  integument  on  the  front  of  the 
ankle,  which  is  redundant  after  excision  of  these  bones,  does  not 
interfere  through  its  bulk,  "bunching,"  with  the  correct  apposition 
of  the  bones.  One  may  overcome  this  tendency  by  passing  several 
quilting  sutures  through  this  mass  of  soft  parts. 

Knee-joint. — A  tourniquet  is  applied  about  the  upper  part  of 
the  thigh.  The  patient  lies  upon  the  back  with  the  leg  extended,  the 
operator  standing  upon  the  side  of  the  table  corresponding  to  the  joint 
which  is  to  be  resected. 

The  usual  incision  (Textor)  and  probably  the  best  for  most 
cases  is  convex  downward,  passing  across  the  front  of  the  joint, 
below  the  patella,  and  extending  from  the  middle  of  one  condyle  to 
a  similar  point  upon  the  other.  This  incision  should  reach  deep  to 
the  bone,  and  below  the  patella  divides  the  ligamentum  patellae. 

The  knee-joint  having  been  thus  opened,  the  limb  is  strongly 
flexed  at  the  hip  and  knee,  with  the  sole  of  the  foot  resting  upon  the 
table,  and  it  is  thus  supported  by  an  assistant.  The  lateral  ligaments 
and  the  lateral  portions  of  the  capsule  are  now  divided,  cutting  them 
close  to  the  surface  of  the  femur. 

The  knee  being  still  more  markedly  flexed,  the  crucial  ligaments 
are  divided  close  to  their  attachment  to  the  upper  surface  of  the  tibia, 
cutting  with  the  edge  of  the  knife  directed  downward,  as  if  one  would 
cut  into  the  articular  surface  of  the  upper  end  of  the  tibia;  if  the 
ligaments  are  divided  with  the  edge  of  the  knife  directed  backward, 
one  may  accidentally  cut  the  popliteal  vessels. 


AMPUTATIONS,  RESECTIONS,  ETC. 


539 


The  anterior  flap,  which  includes  the  patella,  should  be  dis- 
sected back  and  retracted  sufficiently  to  allow  free  access  into  the 
synoyial  pouch,  which  is  located  above  the  patella,  between  the  quad- 
riceps tendon  and  the  front  of  the  femur. 


Pig.  222.— Right  Leg,  Inner  Side.  AS,  incision  upon  the  inner  aspect  of 
the  ankle  for  resection  of  the  astragalus;  K,  Textor  incision  for  resection  of 
the  knee-joint.     Dotted  lines  indicate  planes  of  section  through  the   bones. 


With  mouse-tooth  forceps  and  blunt-pointed  scissors,  curved 
on  the  flat,  the  synovial  membrane  which  lines  the  joint  may  now  be 
entirely  resected.     If  the  bones  are  healthy,  one  may  stop  at  this 


540  LOWER  EXTREMITY. 

stage  of  tlie  operation  and  close  the  wound,  after  irrigating  thor- 
oughly and  providing  for  suitable  drainage  (arthrectomy). 

In  resecting  that  part  of  the  synovial  membrane  which  lines 
the  posterior  part  of  the  capsule  one  should  avoid  cutting  deeply, 
on  account  of  the  liability  to  injure  the  popliteal  vessels,  which  lie 
adjacent  to  this  part  of  the  capsule.  There  is  rather  less  danger 
of  doing  this  if  the  posterior  ligament  is  put  upon  the  stretch  by 
drawing  the  tibia  away  from  the  femur  while  this  part  of  the  syn- 
ovial sac  is  being  excised.  This  portion  of  the  synovial  membrane 
is  also  more  accessible  after  the  ends  of  the  bones  have  been  re- 
sected. 

If  the  disease  in  the  bones  is  limited  to  one  or  more  foci,  these 
may  be  thoroughly  scooped  out  with  a  sharp  spoon,  thus  avoiding 
the  resection  of  the  ends  of  the  bones.  Especially  in  children  one 
should  avoid,  wherever  possible,  the  resection  of  the  ends  of  the 
bones,  since  interference  with  the  epiphyseal  line  may  retard  very 
much  the  subsequent  growth  of  the  limb. 

The  patella  is  usually  extirpated  if  the  ends  of  the  femur  and 
tibia  are  resected,  even  if  it  is  apparently  not  diseased.  It  is  grasped 
with  double  sharp  hooks  and  excised,  cutting  with  the  edge  of  the 
knife  close  to  the  surface  of  the  bone. 

If  one  decides  to  resect  the  ends  of  the  bones,  the  lower  end 
of  the  femur  is  first  removed,  separating  the  soft  parts  back  as  far 
as  necessary,  and  working  with  the  scalpel  close  to  the  bone.  The 
end  of  the  femur,  stripped  of  its  soft  parts,  is  forced  upward,  out 
of  the  wound,  above  the  level  of  the  tibia  (hip  flexed)  and  with 
a  sharp,  broad  saw  the  section  is  made  through  the  end  of  the  bone 
from  before  backward,  commencing  by  placing  the  heel  of  the  saw 
upon  the  bone  and  making  a  groove  by  drawing  the  instrument 
firmly  backward.  The  femur  should  be  steadied  with  both  hands  of 
an  assistant  who  supports  himself  by  resting  his  elbows  upon  the 
table.  The  end  of  the  bone  should  be  forced  sufficiently  far  upward 
out  of  the  wound  so  as  to  make  the  use  of  a  towel  to  protect  the  soft 
parts  during  its  section  unnecessary.  The  piece  of  bone  resected 
must  be  of  the  same  thickness  anteriorly,  posteriorly,  and  upon  either 
side,  otherwise,  when  the  operation  is  completed,  the  limb  will  be 
found  to  be  in  a  position  of  knock-knee  or  bow-leg,  or  there  will  be 
too  much  or  too  little  extension. 

The  section  should  pass  through  a  plane  which  is  parallel  with 
the  articular  surface  of  the  bone,  and  not  at  right  angles  with  the  long 


AMPUTATIONS,  RESECTIONS,  ETC. 


541 


axis  of  the  bone,  and  therefore  in  making  the  section  one  should  dis- 
regard the  long  axis  of  the  bone,  and  rather  keep  his  eye  on  the  plane 
of  the  articular  surface. 

The  end  of  the  tibia  is  now  likewise  stripped  of  its  soft  parts  and 
projected  upward  out  of  the  wound  well  beyond  the  sawn  surface  of 


Fig.  223. — Resection  of  Knee-joint.  A,  A1,  long  axes  of  the  femur  and 
tibia;  B,  line  drawn  at  right  angles  to  the  long  axis  of  the  femur.  C,  lines 
through  the  lower  end  of  the  femur  and  upper  end  of  the  tibia  parallel  with 
the  plane  of  the  articular  surfaces.  Through  these  planes  the  section  should 
be  made  in  resecting  the  knee-joint. 


the  femur,  and  a  section  of  the  bone  removed,  as  in  the  case  of  the 
femur,  parallel  with  the  plane  of  its  articular  surface. 

At  times  it  is  necessary  to  excise  two  or  three  inches  of  the  bones 
(femur  and  tibia  together),  but  one  should  remove  as  little  as  the  con- 
ditions present  will  permit,  especially  in  children.  The  sharp  spoon 
may  be  used  to  extirpate  foci  which  extend  into  the  substance  of  the 


542  LOWER  EXTREMITY. 

bone  beyond  the  surface  exposed  by  the  section,  and,  if  the  cortex  is 
healthy,  one  may  remove  much  of  the  medullary  portion  of  a  bone 
rather  than  sacrifice  more  of  the  length  of  the  limb  by  removing  a 
thicker  segment  of  bone. 

The  limb  should  be  now  extended  and  the  position  of  the  joint 
noted;  when  the  ends  of  the  bones  are  brought  together  there  should 
be  the  normal  slight  bowing  inward  and  a  slight  degree  of  flexion  (five 
degrees). 

If  the  position  of  the  limb  is  not  satisfactory,  one  may  remove  a 
further  section  from  one  of  the  bones  to  correct  it;  but  the  necessity 
for  this  second  section  should  be  avoided. 

The  position  of  the  bones  being  satisfactory,  all  loose,  ragged 
tissue  is  cut  away  and  any  remaining  portion  of  the  synovial  mem- 
brane that  has  been  overlooked  excised. 

In  most  cases  it  is  well  to  insert  tubes  for  drainage,  one  on  each 
side.  These  should  reach  well  up  into  the  recess  beneath  the  quadri- 
ceps muscle,  between  it  and  the  front  of  the  femur;  in  addition,  strips 
of  iodoform  gauze  may  be  packed  into  the  wound,  the  ends  emerging 
through  the  incision  on  each  side;  if  tubes  are  used,  they  should  be 
fixed  to  the  edge  of  the  skin  with  a  silk-worm  gut  stitch  to  prevent 
their  slipping  out.  The  front  part  of  the  skin  incision  is  closed  with 
interrupted  silk-worm  gut  stitches. 

If  the  limb  is  placed  in  a  good,  firm,  plaster-of-Paris  splint,  the 
ends  of  the  bones,  as  a  rule,  remain  in  good  position.  A  sharp  edge  of 
either  bone  should  not  be  left  projecting  into  the  popliteal  space  (pop- 
liteal vessels).  If  it  is  desired  to  fix  the  ends  of  the  bones  they  may 
be  joined  together  with  two  stout  chromicized  catgut  sutures  which 
pass  through  drill  holes  placed  near  the  anterior  margin  of  the  sawn 
surfaces  of  the  bones,  one  on  each  side  of  the  middle  line,  or,  after  the 
skin  has  been  sutured,  the  bones  may  be  joined  by  two  nails,  one 
driven  through  the  front  of  the  upper  end  of  the  tibia  and  reaching 
obliquely  upward  into  the  sawn  surface  of  the  femur,  and  the  other 
passing  through  the  front  surface  of  the  femur  and  reaching  down 
into  the  upper  end  of  the  tibia.  Small  incisions  may  be  made  in  the 
skin  to  allow  the  introduction  of  the  nails. 

These  accessory  measures,  for  the  purpose  of  holding  the  bones 
in  apposition,  are,  as  a  rule,  unnecessary  if  the  ends  of  the  bones  have 
been  sawn  square,  and  fit  well,  and  a  good  plaster  splint  is  applied. 
In  adjusting  the  plaster  splint  one  should  see  that  the  foot  is  slightly 
everted,  so  that  the  patient  will  not  "toe  in." 


AMPUTATIONS,  RESECTIONS,  ETC.  543 

Before  suturing  the  wound  the  tourniquet  may  be  removed  and 
any  spurting  vessels  secured;  usually  there  are  few  or  none,  and  any 
slight  oozing  may  be  controlled  by  the  pressure  of  the  dressing. 

Instead  of  the  incision  described  above  the  knee-joint  may  be 
opened  by  an  incision,  with  the  convexity  directed  upward,  passing 
across  the  limb  above  the  upper  border  of  the  patella.  This  is  the 
reverse  of  the  incision  described  above,  and  gives  very  free  access  to 
the  synovial  pouch  under  the  quadriceps  tendon. 

Volkmann  makes  a  transverse  incision  across  the  front  of  the 
knee,  through  the  skin  down  to  the  surface  of  the  patella,  the  knee 
being  slightly  flexed  and  resting  upon  a  sand  bag;  corresponding  to 
this  incision  through  the  skin,  the  patella  is  sawn  through  trans- 
versely. To  this  may  be  added  two  lateral  incisions,  one  on  each  side 
of  the  joint  running  up  and  down.  We  then  have  an  H-shape  in- 
cision. This  incision  is  especially  adapted  to  those  cases  where  the 
disease  is  limited  to  the  synovial  membrane  alone;  so  that  after  its 
excision  the  segments  of  the  patella  may  be  sutured  with  chromi- 
cized  catgut.     This  incision  is  often  desirable  in  children. 

Hip-joint  (Langenbeck).  —  This  operation  is  done  as  much 
as  possible  subperiosteally.  The  patient  lies  upon  the  well  side  of 
the  body,  with  the  hip  and  knee  slightly  flexed.  A  longitudinal  in- 
cision is  made  over  the  outer  side  of  the  hip  four  to  five  inches  long; 
it  commences  two  or  three  inches  above  the  upper  border  of  the  great 
trochanter,  upon  a  line  corresponding  to  the  long  axis  of  the  femur, 
and  from  this  point  is  continued  straight  down  upon  the  outer  surface 
of  the  trochanter  and  ends  upon  the  upper  part  of  the  shaft  of  the 
femur;  the  incision  throughout  its  whole  length  penetrates  to  the 
bone;  that  portion  of  the  incision  which  lies  above  the  trochanter 
passes  through  the  fibers  of  the  glutei  muscles  down  to  the  surface 
of  the  ilium,  which  it  reaches  just  above  the  margin  of  the  acetabulum, 
exposing  the  capsule  of  the  joint. 

Sharp  retractors  are  inserted  deep  in  the  incision  and  the  soft 
parts  drawn  forcibly  asunder.  The  capsule  is  incised  from  the  rim 
of  the  acetabulum  downward  toward  the  great  trochanter,  the  coty- 
loid ligament,  also,  being  nicked,  or  may  be  separated  from  the  bony 
rim  of  the  acetabulum  for  a  short  distance  on  either  side  of  the  in- 
cision in  the  capsule. 

With  the  periosteum  elevator,  or,  where  necessary,  with  the  knife 
or  chisel,  the  tendons,  together  with  the  periosteum  and  the  capsule, 
are  separated  from  the  greater  trochanter  and  the  neck  of  the  femur; 


544  LOWER  EXTREMITY. 

this  should  be  accomplished  as  much  as  possible  subperiosteal^  with 
the  sharp-edged  periosteum  elevator;  but,  where  the  attachment  of 
the  parts  to  the  bones  is  very  intimate,  it  may  be  necessary  to  resort 
to  the  knife,  cutting  with  its  edge  close  to  the  surface  of  the  bone,  or 
the  chisel  may  be  used,  chipping  off  a  thin  shell  of  the  cortex,  which 
carries  the  attached  tendons  with  it.  An  assistant  rotates  the  limb 
inward  or  outward  as  may  be  necessary  to  facilitate  this  part  of  the 
operation. 


Pig.  224. — Resection  of  Hip.    Langenbeck's  incision. 

In  this  way  the  upper  end  of  the  femur  is  denuded.  Pains 
should  be  taken  to  separate  the  tendon  of  the  obturator  externus, 
which  is  attached,  in  the  digital  fossa,  upon  the  inner  aspect  of  the 
great  trochanter,  and  also  the  tendons  that  are  attached  to  the  upper 
border  of  the  great  trochanter. 

In  order  to  cut  the  ligamentum  teres  the  thigh  is  flexed,  rotated 
inward,  and  adducted,  in  this  way  partly  luxating  the  head  of  the 
bone;    a  long,  narrow  knife  is  then  introduced  into  the  joint  above 


AMPUTATIONS,  RESECTIONS,  ETC. 


545 


and  behind,  and  sweeping  downward  and  forward  across  the  head 
of  the  bone,  the  ligament  is  usually  cut.  In  operating  on  diseased 
joints  it  is,  as  a  rule,  not  necessary  to  cut  the  ligamentum  teres,  as  it 
is,  in  most  cases,  already  destroyed,  or,  at  any  rate,  readily  ruptures 
upon  forcibly  manipulating  the  joint  (adduction  and  rotation  inward). 
The  head  of  the  femur  is  then  completely  luxated  backward  by 


Fig.  225. — Resection  of  the  Hip.  Anthony  White's  incision.  Commences 
anteriorly  midway  between  the  anterior  superior  spine  of  the  ilium  and  the 
upper  border  of  the  trochanter  major  and  curves  backward  above  the  tro- 
chanter major  and  then  downward  behind  the  trochanter  for  a  distance  of 
about  two  inches. 


manipulation  (flexion,  adduction,  and  rotation  inward)  and  forced  out 
of  the  wound,  when  the  head  and  neck  may  be  readily  removed  with  a 
Gigli  or  chain  saw,  with  a  flat  saw,  or  with  a  chisel. 

Some  surgeons  make  it  a  practice  to  remove  the  trochanter  as 
well  as  the  head  and  neck  of  the  femur,  making  the  line  of  section 
through  the  shaft  of  the  bone  just  below  the  great  trochanter.     In 


546  LOWER  EXTREMITY. 

order  to  do  this  it  is  necessary  to  separate  the  periosteum,  etc.,  corre- 
spondingly lower  down  upon  the  shaft  of  the  femur.  If  the  trochanter 
is  healthy,  it  is  unnecessary  to  remove  it;  yet,  if  at  all  suspicious,  it  is 
better  to  make  the  section  through  the  bone  below  the  great  tro- 
chanter, removing  the  great  trochanter  as  well  as  the  head  and  neck, 
because  the  result  is  just  as  good,  and  many  surgeons  claim  better, 
than  when  it  is  left. 

Now,  rotating  inward  and  outward,  but  chiefly  by  extension  of 
the  limb,  pulling  strongly  upon  the  femur  and  holding  the  edges  of 
the  wound  widely  apart  to  give  us  room,  we  may  proceed  to  excise  the 
synovial  membrane,  using  long,  sharp  scissors,  curved  upon  the  flat, 
and  mouse-tooth  forceps. 

If  the  acetabulum  is  diseased,  it  may  be  curetted  with  a  sharp 
spoon  or  even  resected  with  the  chisel  and  mallet.  A  sinus  may  be 
found  leading  through  the  acetabulum  to  a  focus  within  the  pelvis,  in 
which  case  drainage  of  the  joint  may  be  combined  with  counter-drain- 
age through  an  incision  made  anteriorly  just  below  Poupart's  liga- 
ment. There  is  but  little  hemorrhage  during  the  operation;  bleed- 
ing vessels  may  be  seized  as  they  are  cut  during  the  progress  of  the 
operation. 

The  soft  parts  are  brought  together  with  interrupted  silk-worm 
gut  sutures,  which  should  pass  deep  through  the  integument,  mus- 
cles, and  periosteum,  closing  the  wound,  except  for  a  space  below 
sufficient  to  allow  the  passage  of  a  thick  tube,  which  should  reach 
upward  as  far  as  the  acetabulum  for  drainage,  or  the  wound  may  be 
packed  with  iodoform  gauze,  or  the  gauze  packing  may  be  combined 
with  the  use  of  a  tube.  Before  closing  the  wound  it  should  be  washed 
out  with  hot  bichloride  solution. 

During  the  operation  one  should  work  as  much  as  possible  Avith 
the  periosteum  elevator  and  chisel,  cutting  as  few  tendons  as  pos- 
sible with  the  knife.  We  should  strive  to  keep  the  capsule  and  the 
periosteum  or  shell  of  cortex  that  is  separated  from  the  bone,  along 
with  their  attached  tendons,  hanging  together  in  one  continuous 
layer;  so  that,  when  we  are  ready  to  resect,  the  denuded  upper  end 
of  the  femur  lies  in  a  sort  of  sac  which  is  made  of  the  above  named 
structures,  and  which  all  hang  together,  continuous  with  one  an- 
other, and  it  is  out  of  this  hood  or  sac  that  we  deliver  the  upper  end 
of  the  bone  for  resection.  In  closing  the  wound  the  upper  edges  of 
the  hood  should  be  included  in  the  sutures,  except  the  part  that  is 
left  open  for  drainage. 


AMPUTATIONS,  RESECTIONS,  ETC. 


547 


Osteotomy  of  the  Femur  for  Genu  Valgum — Knock-knee  (Mac- 
ewen). — The  knee  is  somewhat  flexed,  its  outer  side  resting  upon 
a  sand  hag.  A  short  longitudinal  incision  is  made  upon  the  inner 
side  of  the  thigh  just  above  the  knee-joint.  It  is  placed  one  finger's 
breadth  in  front  of  the  tendon  of  the  adductor  magnus,  its  lower 


FA. 


AM  4 


Fig.  226.— Osteotomy  (Macewen).  A.M.,  opening  in  the  adductor  magnua 
through  which  the  femoral  artery  (F.A.)  passes  into  the  popliteal  space. 
Arrow  indicates  point  at  which  the  chisel  is  applied  and  the  dotted  line  the 
plane  of  section  for  bow-legs  and  knock-knee. 


end  upon  a  line  which  is  drawn  around  the  lower  part  of  the  thigh 
one  finger's  breadth  above  the  upper  border  of  the  external  con- 
dyle; or  we  may  locate  the  lower  end  of  the  incision  two  fingers' 
breadth  above  the  inner  condyle  and  one  finger's  breadth  in  front  of 
the  tendon  of  the  adductor  magnus.    The  incision  is  prolonged  upward 


548  LOWER  EXTREMITY. 

for  a  distance  of  4  cm.  and  reaches  to  the  hone  through  the  integu- 
ment, vastus  internus  muscle,  and  periosteum. 

The  periosteum  is  separated  from  the  surface  of  the  hone  over 
an  area  sufficient  to  allow  the  application  of  a  hroad  chisel,  with 
which  the  bone  is  divided,  in  a  direction  outward  and  slightly  upward. 
The  line  of  fracture  does  not  pass  through,  hut  just  above,  the  joint. 
The  deformity  is  then  corrected,  and  the  limb,  including  the  foot, 
placed  in  a  plaster  splint. 

It  is  not  necessary  to  chisel  through  the  entire  thickness  of  the 
shaft  of  the  femur,  but  only  far  enough  to  allow  one  to  gradually  bend 
the  bone  into  position — it  should  not  be  forcibly  fractured  or  bent  into 
position  with  a  sudden  jerk.  The  line  of  fracture  is  placed  above  the 
epiphyseal  line,  and  therefore  this  operation  may  be  done  upon  chil- 
dren and  young  people  without  interfering  with  the  natural  subse- 
quent growth  of  the  femur.  This  operation  may  also  be  done  through 
an  incision  upon  the  outer  aspect  of  the  limb  upon  the  same  level. 

Suture  of  the  Patella. — Approximation  and  fixation  of  the  frag- 
ments of  the  patella  in  case  of  fracture  with  marked  separation,  etc. 

The  failure  to  obtain  bony  union  in  fracture  of  the  patella  is 
due  to  the  interposition  of  strings  of  torn  periosteum,  etc.,  and 
blood-clot  between  the  fragments,  and  to  distension  of  the  capsule 
of  the  knee-joint  with  blood  and  serum.  These  conditions  interfere 
with  immediate  close  coaptation  of  the  fragments.  The  object  of  an 
operation  is  to  approximate  and  fix  the  fragments  and  to  evacuate 
the  knee-joint. 

A  vertical  incision  is  made  sufficiently  long  to  expose  the  frag- 
ments, the  edges  of  the  wound  being  drawn  asunder  with  sharp- 
pronged  retractors.  Each  fragment  is  then,  in  turn,  lifted  up  into 
the  wound  with  a  sharp  hook  and  its  edge  freed  from  shreds  of 
periosteum  and  blood-clot.  The  blood  is  then  turned  out  of  the 
joint  and  the  joint  irrigated  with  a  warm  saline  solution.  The  frag- 
ments are  then  brought  together  with  sharp  hooks  and  fixed  in  posi- 
tion with  two  or  more  chromicized  catgut  sutures.  These  sutures 
should  include  the  periosteum  corresponding  to  the  edges  of  the 
fragments  and  should  take  a  good,  firm  bite.  It  is,  in  most  cases, 
unnecessary  to  carry  these  sutures  through  the  bone.  If  this  should 
be  desirable,  however,  the  holes  must  be  drilled  through  the  edges 
of  the  fragments.  These  drill  holes  should  not  go  through  the  entire 
thickness  of  the  bone,  but  only  partly  through,  emerging  upon  the 
edges  of  the  fragments. 


AMPUTATIONS,  RESECTIONS,  ETC. 


549 


After  the  fragments  have  been  united  the  rents  in  the  capsule, 
fibrous  expansion  of  the  quadriceps  extensor  tendon  upon  either  side, 
corresponding  to  the  lateral  margins  of  the  patella,  may  also  be 
closed  with  several  catgut  sutures.  The  incision  in  the  skin  is  su- 
tured with  catgut  without  drainage,  an  aseptic  dressing  is  applied, 


Fig.  227. — Wiring  Patella  for  Fracture.  Shows  tear  in  capsule  upon  either 
side  of  fractured  patella.  Sutures  emerge  upon  the  edge  of  each  fragment: 
i.e.,  they  do  not  pass  entirely  through  the  whole  thickness  of  the  bone. 

and  the  limb  placed  upon  a  long  posterior  splint  with  the  foot  ele- 
vated and  the  limb  flexed  at  the  hip-joint  so  as  to  relax  the  quad- 
riceps. After  one  week  the  limb  may  be  placed  in  plaster,  still  kept 
flexed  at  the  hip,  and  at  the  end  of  four  weeks  passive  motion  may  be 
commenced. 


INDEX. 


[The  names  of  arteries,  muscles,  nerves,  and  veins  are  placed  in  the  index  under  the  headings 
"Artery,"  "Muscle,"  etc.] 


Abbe,   operation   for   stricture   of   oesophagus, 

230. 
Abdomen,  205. 
antero-lateral  wall  of,  207. 
muscles  of,  208. 

aponeuroses  of,  210. 
posterior  wall  of,  206. 
Abdominal  cavity,  205. 
wall,  deep  vessels  of,  212. 
superficial  vessels  of,  208. 
Abscess,  extradural,  in  middle  fossa,  50. 
of  breast,  incisions  for,  194. 
of  cerebellum,  50. 
temporo-sphenoidal,  51. 
Alexander,  prostatectomy,  434. 
Alimentary  tube,  80. 
Alveolar  process,  cleft  of,  92. 
Amputation  of  arm,  461. 
of  breast,  195. 
of  finger  at  phalango-phalangeal  joint,  450. 

at  metacarpo-phalangeal  joint,  452. 
of  foot  through  medio-tarsal  joint,  Chopart, 
504. 
Pirogoff  method,  507. 
Giinther  modification.  509. 
le  Fort  modification,  509. 
Syme  method,  506. 

through   tarso-metatarsal   joint,    Lisfranc, 
501. 
of  forearm,  457. 
of  leg,  510. 
of  penis,  422. 
of  rectum,  Kraske,  361. 

Volkmann,  348. 
of  thigh,  521. 
of  toe,  500. 
of  tongue,  159. 
Anaesthesia,  cocain,  2. 
general,  1. 

incomplete,  1. 
local,  2. 
Schleich  method,  3. 
Anal  fascia,  425-430. 
Analgesia  by  subarachnoid  injection  of  cocain, 

3. 
Anastomosis,   intestinal    (see   "Intestinal   An- 
astomosis"). 
Angiotribe,  11. 
Ankle-joint,  505. 
exarticulation  of  foot  at,  506. 
Pirogoff  method,  507. 
Giinther  modification,  509. 
le  Fort  modification,  509. 
Syme,  506. 
resection  of,  Koenig,  533. 
Langenbeck-Hueter,  529. 
Lauenstein,  535. 
Mikulicz-Wladimirow,  536. 
with  extirpation  of  astragalus,  532. 
Antrum  of  Highmore,  53. 
to  drain,  69. 
mastoid,  40. 
drilling  into,  46. 
to  open  and  drain,  46. 
Anus,  artificial,  289. 
Aorta,  arch  of,  182. 
thoracic,  187. 


Aortic  valve  (orifice),  181. 
Aponeurosis  of  abdominal  muscles,  210. 

of  external  oblique,  209,  364. 
Appendicectomy,  299. 
incision,  299. 
Battle,  301. 
McBurney,  300. 
Appendicitis    accompanied    by    general    peri- 
toneal infection,  operation,  309. 
Appendicular  abscess,  operation,  306. 
Appendix  vermiformis,  amputation  of,  299. 
inversion  of,  305. 

stump  of,  after  amputation,  304.  • 
ligation  of  stump  of,  without  inversion,  302. 
surgical  anatomy  of,  285. 
Aqueductus  Fallopii,  45. 
Arch,  mandibular,  82. 

of  aorta,  182. 
Arches,  visceral,  82. 
Arm,  amputation  of,  461. 
Arteries  of  scalp,  19. 
Artery,  anterior  tibial,  492. 
ligation  of,  494. 
axillary,  437. 

ligation  of,  447. 
brachial,  440. 

ligation  of,  448. 
common  carotid,  136. 

ligation  of,  153. 
common  carotid,  left,  188. 
deep  epigastric,  367. 
dorsalis  pedis,  493. 
external  carotid,  138. 

ligation  oi,  155. 
facial,  52. 
femoral,  486. 

ligation  of,  489. 
inferior  thyroid,  141. 
innominate,  188. 
intercostal,  ligation  of,  200. 
internal  carotid,  33,  137. 

ligation  of,  156. 
internal  mammary,  170. 

ligation  of,  200. 
internal  maxillary,  60. 
lingual,  58,  127. 

ligation  of,  158. 
middle  meningeal,  25. 

ligation  of,  25. 
musculo-phrenic,  170. 
obturator,  380. 
posterior  tibial,  494. 

ligation  of,  496. 
radial,  443. 

ligation  of,  449. 
subclavian,  140. 

ligation  of,  156. 
subclavian,  left,  loo. 
superior  epigastric,  170. 
temporal,  60. 
ulnar,  443. 

ligation  of,  449. 
vertebral,  141. 
Ascending  colon,  287. 
Atresia  of  facial  orifices,  90. 
Auditory  canal,  external,  42-87. 
process,  42. 


(551) 


552 


INDEX. 


Auricle,  42.-87. 

Auriculo-ventricular  valves  (orifices),  182. 
Axilla,  surgical  anatomy  of,  437. 
Axillary  abscess,  incision  for,  440. 

line,  171. 

vein   (see  "Artery,  axillary"). 
Azygos  vein,  187. 

Back,  214. 

muscles  of,  215. 

of  neck,  120. 
Bardeleben  operation  for  harelip,  106. 
Bassini  operation  for  inguinal  hernia,  383. 
Bier,  subarachnoid  injection,  335. 
Big  toe,  exarticulation  of,  500. 

with  removal  of  first  metatarsal  bone,  500. 
Billroth,  extirpation  of  tongue,  164. 

pylorectomy,  237. 
Bladder,    drainage   of    (see    "Suprapubic   cys- 
totomy"). 

operation    for    stone    in    (see    "Suprapubic 
cystotomy"). 

puncture,  418. 

relations  of,  414. 

surgical  anatomy  of,  413. 

suture  of  wounds  of,  17. 
Blandin's  method,  harelip,  106. 
Bone,  division  of,  5. 

suture  of,  15. 
Bottini,  prostatotomy,  435. 

Bowel,  suture  of  wounds  of,  16  (see  also  "In- 
testine," etc.). 
Branchial  arches  (see  "Visceral  arches"). 

clefts  (see  "Visceral  clefts"). 
Breast,  175. 

amputation  of,  195. 
Halsted-Meyer  method,  197. 

extirpation  of  fibroid  from,  195. 

fibroid  of,  195. 

incisions  for  abscess  of,  194. 

lymphatics  of,  176. 
Bruns  method,  formation  of  lower  lip,  113. 
Bursas  adjacent  to  knee-joint,  515. 

Caecum,  resection  of,  295. 

surgical  anatomy  of,  285. 
Canal,  crural,  375-380,  488. 

external  auditory,  87. 

Hunter's,  487. 

inguinal,  365. 
Carden  amputation  of  leg,  518. 
Carotid  artery,  common,  136. 
ligation  of,  153. 
left,  188. 

external,  138. 
ligation  of,  155. 

internal,  137. 
ligation  of,  156. 

triangle,  inferior,  123. 
superior,  125. 
Casserian  ganglion,  34. 

extirpation  of,  Hartley-Krause,  36. 
Rose-Andrews  method,  76. 
Castration,  401. 
Cavernous  sinus,  22-33. 
Cavum  Meckelii,  35. 
Cerebellar  abscess,  50. 
Cerebro-spinal  fluid,  23. 
Cervical  fascia,  deep,  118. 
Cheeks,  54. 
Chest,  fascia  of,  169. 

aspiration  (see  "Thoracentesis"). 

tapping  (see  "Thoracentesis"). 
Chest  wall,  muscle  of,  169. 

resection  of  part  of,  202. 
Cholecystectomy,  322. 
Cbolecyst-enterostomy,  324. 
Cholecysto-dnodenostomy    with    Murphy    but- 
ton, 325. 


Cholecystostomy,  318. 

in  one  sitting,  318. 

in  two  sittings,  320. 

McBurney  modification,  319. 

when  bladder  cannot  be  drawn  into  incision 
for  fixation,  322. 

when  bladder  is  already  fixed  by  adhesions 
to  abdominal  wall,  322. 
Cholecystotomy,  315. 
Choledocho-lithectomy,  326. 
Choledocho-lithotripsy,  327. 
Choledochotomy,  326. 
Chopart  amputation,  504. 

joint,  499. 
Circumcision,  421. 

with  clamp,  422. 
Clavicular  region,  173. 
Cleft  of  alveolar  process,  92. 
palate,  93. 

operation  for,  107. 
Clefts,  lateral  nasal,  96. 

median,  of  upper  lip,  95. 

oblique  facial  clefts,  86,  96. 

of  lower  lip,  lower  jaw,  and  tongue,  98. 

orbito-nasal   (see  "Oblique  facial  clefts"). 

transverse  facial,  87,  98. 

visceral,  82. 
Cocain  anaesthesia,  2. 

sterilization,  4. 

subarachnoid  injection  of,  3  (see  also  "Lum- 
bar puncture,"  334). 
Coccyx,  339. 
Colles's  ligament,  364. 
Colon,  resection  of  (see  "Resection  of  caecum" 

and  "Sigmoid  flexure"). 
Colostomy,  289. 

Maydl  method,  292. 
Common  bile-ducts,  313. 
Congenital  deformities  of  face,  80,  90. 
classification  of,  90. 

hernia,  inguinal,  370,  371,  Fig.  152. 
operation  for,  388. 
Conjoined  tendon,  866. 
Conus  terminalis,  220. 
Cooper,  pubic  ligament  of,  372,  374,  379. 
Corning,  spinal  injection,  334. 
Corpora  cavernosa,  418. 
Corpus  spongiosum,  418. 
Costal  cartilages,  168. 
Costo-coracoid  membrane,  175. 
Cotting  operation,  501. 
Cowper's  gland,  427. 
Craniectomy,  29. 
Craniotomy,  linear,  29. 
Cribriform  fascia,  363. 
Crico-thyroid  membrane,  132. 
Crico-tracheotomy,  143. 
Crural  canal,  375-380,  488. 

nerve,  anterior,  489. 

ring,  375-380. 
Cushing  suture,  17. 
Cystic  duct,  312. 
Cystotomy,  suprapubic,  415. 

Dawbarn,  inversion  of  stump  of  appendix,  304. 
Dartos,  394. 

Deformities  of  face,  congenital,  80,  89. 
classification  of,  90. 
in  which  first  visceral  arch  is  concerned, 

98. 
in  which  frontal  palate  is  concerned,  91. 
Deltoid  flap,  exarticulation  of  arm  at  shoulder- 
joint,  469. 
Depressed    fracture   of   skull,    trephining   for, 

23. 
Descending  colon,  anatomy  of,  288. 
Development  of  ear,  40. 
Diaphragm,  171-205. 
uro-genital,  427. 


INDEX. 


553 


Dieffenbach  Wellenschnitt,  103,  116. 

resection  of  rectum,  351. 
Dieffenbach-Jaesche   operation   for   lower  lip, 

112. 
Dilatation  of  sphincter,  342. 
Diploe,  20,  21. 
Division  of  bone,  5. 

of  soft  parts,  4. 
Dorsal  section,  419. 

Roser  method,  420. 
Drum  of  ear,  43,  87. 
Dubrueil,  exarticulation  of  hand,  456. 
Duct,  common  bile-,  313. 

cystic,  312. 

ejaculatory,  395. 

hepatic,  313. 

Stenson's,  55,  59. 

tear-,  86. 

thoracic,  188. 

Wharton's,  57. 
Ductus  communis  choledochus,  313. 
Duodenotomy  for  impacted  gall-stone,  327. 
Duodenum,  247. 
Dura  mater,  21. 

of  spinal  cord,  220. 

sinuses  of,  22. 

Ear,  development  of,  41. 
middle,  43. 

surgical  anatomy  of,  41. 
Ear-drum,  43,  87. 

Edebohls,  decortication  of  kidney,  412. 
inversion  of  appendix,  305. 
nephropexy,  407. 
Ejaculatory  ducts,  395. 
Elbow,  space  in  front  of,  442. 
Elbow-joint,  exarticulation  of  forearm  at,  460. 
resection  of,  474. 
surgical  anatomy  of,  458. 
End-to-end  anastomosis,  small  intestine,  257. 
Mounsell  method,  259. 
with  Laplace  forceps,  264. 
with  Murphy  button,  261. 
with  O'Hara  forceps,  266. 
with  suture,  257. 
large  intestine,  296. 
End-to-side,   lateral   implantation    (intestine), 

298. 
Enterectomy,  254. 

Entero-anastomosis    (see    "Intestinal    anasto- 
mosis," etc.). 
Enterorrhaphy,  252. 
Epididymis,  395. 

Esmarch,   exarticulation  of  arm  at  shoulder- 
joint,  467. 
Esmarch's  bandage  and  constrictor,  6. 
Estlander,  thoracectomy,  202. 
Estlander's  method,  restoration  of  lip,  115. 
Ethyl  chloride,  2. 
Eustachian  tube,  45-87. 

Exarticulation  of  arm  at  shoulder-joint,   del- 
toid flap,  469. 
Spence  method,  465. 
with  Esmarch  constrictor,  467. 
of  big  toe,  500. 

with  removal  of  metatarsal  bone,  500. 
of  finger,  450. 

at  metacarpo-phalangeal  joint,  452. 
of  foot  at  ankle-joint,  Pirogoff  method,  507. 
Gunther  modification,  509. 
le  Fort  modification,  509. 
Syme  method,  506. 
of  forearm  at  elbow-joint,  460. 
of  hand,  Dubrueil,  456. 

at  carpo-metacarpal  articulation,  453. 
of  leg  at  knee-joint,  Carden,  518. 
Gritti-Stokes,  520. 
Stephen  Smith,  516. 
of  little  toe,  500. 


Exarticulation  of  thigh  at  hip-joint  (Wyeth's 
pins),  526. 
with  preliminary  ligation  of  common  fem- 
oral, 529. 
of  toes,  500. 
Excision  of  internal  jugular  vein,  49. 
Excision  of  joints  (see  "Resection"). 

Face,  classification  of  deformities  of,  90. 
congenital  deformities  of,  80,  89. 
in  which  first  visceral   arch   is  concerned, 

98. 
in  which  frontal  plate  is  concerned,  91. 
development  of,  80. 
side  of,  58. 
skeleton  of,  52. 
surgical  anatomy  of,  51. 
Facial  cleft,  oblique,  86,  96. 
transverse,  87,  98. 
vein,  126. 
Falciform  process,  372-485. 
Fallopii,  aqueductus,  45. 
Fascia,  anal,  425,  430. 
deep  cervical,  IIS. 

connective  tissue  spaces  beneath,  119. 
deep  perineal   (see  "Triangular  ligament"}. 

427-429. 
endothoracica,  169. 
iliaca,  218,  373,  379. 
lata,  372,  482. 
iliac  portion  of,  372. 
pubic  portion  of,  372. 
lumbar,  217. 
pectineal,  379. 
perineal,  deep,  427,  429. 

superficial,  424. 
spermatic,  394. 
superficial  of  groin,  362. 
temporal,  19. 
transversalis,  211. 
Fascia?  of  chest,  169. 

of  thorax,  169. 
Fauces,  isthmus  of,  55. 
Femoral  artery,  486. 
ligation  of,  489. 
hernia,  380. 

operation  for,  392. 
region,  372. 
anterior,  485. 

from  within  abdomen,  378. 
sheath,  374-380,  488. 
space,  374-379. 

vein  (see  "Femoral  artery"). 
Fenger's  incision,  224. 
Fifth  (trifacial)  nerve,  33. 
division  of  branches  at  base  of  skull,  Kron- 

lein-Liicke,  79. 
inferior  maxillary  branch,  63. 
superior  maxillary  branch,  63. 
Filum  terminale,  220. 
Finger,  exarticulation  of,  450. 

at  metacarpo-phalangeal  joint,  452. 
Fistula  in  ano,  342. 
operation  for  complete,  343. 
for  incomplete,  344. 
Foot,  amputation  of,  Chopart,  504. 
Lisfranc,  501. 
exarticulation  of,  Gunther,  509. 
le  Fort,  509. 
Pirogoff,  507. 
Syme,  506. 
surgical  anatomy  of,  498. 
Foramen  lacerum  medium,  30. 
obturator,  380. 
ovale,  31. 
rotundum,  31,  63. 
spinosum,  31. 
Forceps,  Laplace,  264. 
McLean,  264. 


554 


INDEX. 


Forceps,  O'Hara,  266. 

Forcipressure,  11. 

Forearm,  amputation  through,  457. 

Forebrain,  vesicle  of,  81. 

Fossa  cruralis,  378. 

ischio-rectal,  425. 

spheno-maxillary,  62. 

zygomatic,  61. 
Fovea  inguinalis  externa,  377. 

inguinalis  interna,  378. 

supravesicalis,  378. 
Fowler,  pleurectomy,  203. 
Frontal  plate  or  process,  83,  84,  87. 

sinus,  21. 

Gall-bladder,  aspiration  of,  315. 

excision  of  ("Cholecystectomy"). 

incision  into  (see  "Cholecystotomy"). 

operations  upon,  315. 

surgical  anatomy  of,  312. 
Gall-ducts,    operations    upon,    326     (see    also 

•'Gall-bladder"). 
Ganglion,  Meckel's,  64. 

Casserian  (see  "Casserian  ganglion"). 
Gastrectomy,  244. 
Gastro-enterostomy,  272. 

anterior,  272. 

Carle,  281. 

Jaboulay  and  Braun,  278. 

posterior,  276. 

vicious  circle  after,  279. 

von  Hacker,  276. 

with  Laplace  forceps,  283. 

with  McGraw's  rubber  suture,  281. 

with  Murphy  button,  280. 

with  O'Hara  forceps,  284. 

Woelfler,  272. 
Gastroplication,  226. 
Gastrorrhaphy,  237. 
Gastrostomy,  232. 

Ssabanajew  and  Franck,  233. 

von  Hacker,  232. 

Witzel,  235. 
Gastrotomy,  228. 
Gimbernat's  ligament,  365-379. 
Gland,  Cowper's,  427. 

parotid,  59. 

prostate,  428. 

sublingual,  57. 

thyroid,  134. 
Gluteal  region,  482. 
Gritti-Stokes  amputation  of  leg,  520. 
Groin,   lymphatic  glands  of,  362. 

superficial  fascia  of,  362. 

surgical  anatomy  of,  362. 
Giinther  modification  of  Pirogoff  amputation, 
509. 


Hagedorn  operation  for  harelip,  103. 
Halsted  operation  for  inguinal  hernia,  389. 
Halsted-Meyer  amputation  of  breast,  197. 
Hand,   exarticulation  of,   at  carpo-metacarpal 
joint,  453. 

exarticulation  of,  Dubrueil,  456. 

incision  into,  446. 

nerve-supply  of,  446. 

surgical  anatomy  of,  445. 
Harelip,  86-91. 

Bardeleben's  operation  for,  106. 

Blandin's  operation  for,  106. 

Hagedorn's  operation  for,  103. 

Malgaigne  operation  for,  101. 

Mirault  operation  for,  102. 

Nelaton  operation  for,  100. 

operations  for,  98. 
complete,  102. 

double,     with     advanced     intermaxillary 
process,  105. 


Harelip,  double,  without  advanced  intermaxil- 
lary process,  104. 
incomplete,  100. 

single    complete,    with    cleft    of    alveolar 
process  and  advancement  of  intermax- 
illary bone,  104. 
von  Graefe  operation  for,  100. 
Hartley  chisel,  26. 
Head,  19. 

surgical  anatomy  of,  19. 
Heart,  179. 

outlines  of,  upon  chest  wall,  180. 
Hemiazygos  vein,  188. 
Hemorrhage,  5. 
artificial  arrest  of,  6. 
control  of,  by  chemical  agents,  10. 
by  digital  compression  in  the  wound,  10. 
by    digital    compression    of    main    vessels 

proximal  to  wound,  8. 
by  direct  means,  9. 
by  forcipressure,  11. 
by  heat  and  cold,  9. 
by  indirect  means,  6. 
by  ligature,  11. 
by  mechanical  means,  10. 
by  position,  8. 
by  preliminary  ligation,  8. 
by  suture,  11. 
by  tamponade,  10. 
by  torsion,  11. 
through  nervous  system,  9. 
with  Esmarch  bandage,  etc.,  6. 
intracranial,  trephining  for,  25. 
from  middle  meningeal,  25,  28. 
natural  arrest  of,  6. 
Hemorrhoids,  342-344. 
operations  for,  344. 
clamp  and  cautery,  346. 
ligation  and  excision,  345. 
Henle's  spine  (see  "Spina  supra  meatum").' 
Hepatectomy,  315. 
Hepatic  duct,  313. 
Hepatotomy,  314. 
Hernia.  362. 
femoral,  375,  380. 

operations  for,  392. 
inguinal,  36S. 
acquired,  371. 
Bassini  operation  for,  383. 
congenital,  370,  371,  378,  Fig.  152. 

operation  for,  Bassini,  3bs. 
direct  (see  "H.,  internal"), 
external    or    oblique,    368,    370    (see    also 
"Fovea  inguinalis  externa,"  377). 
operation  for,  Bassini,  383  (see  also  Hal- 
sted's,  below). 
Halsted's  operation  for,  389. 
indirect  (see  "H.,  external"), 
infantile  or  encysted,  371. 
internal  or  direct,  368,  370  (see  also  "Fovea 
inguinalis  interna,"  378). 
operation  for  Bassini,  3S9  (see  also  Hal- 
sted's, above), 
oblique  (see  "H.,  external"), 
strangulated,  operation  for,  380. 
Herniotomy,  380. 
Highmore,  antrum  of,  53. 
operation  to  drain,  69. 
Hip-joint,  relations  of  parts  behind,  483. 
resection  of,  Langenbeck,  544. 

Anthony  White  incision,  545,  Fig.  225. 
surgical  anatomy  of,  523. 
Hunter's  canal,  487. 
Hydrocele,  open  operation  for,  398. 
puncture  and  injection,  397. 
retroversion  of  tunica  vaginalis,  400. 
Volkmann  operation,  398. 
von  Bergmann  operation,  399. 


INDEX. 


555 


Hydrocele,  Winkelrnann  operation,  400. 
Hyoid  bone,  130. 

Idiocy,  craniectomy  for,  29. 
Ileo-colostomy,  296,  298. 
end-to-end,  296. 
end-to-side,  298. 

lateral  (side-to-side)  anastomosis,  297. 
without  resection  of  caecum,  298. 
Ileum,  249. 
Iliac  fascia  (see  "Fascia  iliaca"). 

portion  of  fascia  lata,  372. 
Ilio-pectineal  ligament,  374-379. 
Ilio-psoas  space,  374. 
Inferior  maxilla  (see  "Lower  jaw"). 
Inferior  maxillary  branch  of  fifth  nerve   (see 

"Fifth  nerve"). 
Infraclavicular  region,  174. 
Infrahyoid  region,  130. 
Infundibular  process,  367. 
Infusion,  intravenous,  480. 
Ingrowing  toe-nail,  operations  for,  501. 
Inguinal  canal,  365. 
hernia  (see  "Hernia"), 
region,  363. 

from  within  abdomen,  375. 
ring,   internal,   366,  377. 
external,  364. 
Innominate  artery,  188. 
Intermaxillary  bone,  87. 
Internal  jugular  vein,  ligation  and  excision  of, 

49. 
Intestinal   anastomosis,    large   intestine,    end- 
to-end,  296. 
lateral,  297. 
side-to-side,  297. 
small  intestine,  end-to-end,  257. 
Mounsell  method,  259. 
with  Laplace  forceps,  264. 
with  Murphy  button,  261. 
with  O'Hara  forceps,  266. 
with  suture,  257. 
lateral,  with  Laplace  forceps,  272. 
with  McGraw  rubber  suture,  271. 
with  Murphy  button,  271. 
with  O'Hara  forceps,  272. 
with  suture,  268. 
side-to-side  (see  lateral,  above). 
Intestinal  clamp  or  compressor,  255,  Fig.  106. 
Intestine,  large,  blood-supply  of,  288. 
operations  upon,  289. 
surgical  anatomy  of,  285. 
resection  of  part  of,  254. 
small,  blood-supply  of,  251. 
operations  upon,  252. 
surgical  anatomy  of,  247. 
suture  of  wounds  of  (see  "Enterorrhaphy"). 
Intracranial  hemorrhage,  25. 

trephining  for,  25. 
Intravenous  infusion,  480. 
Ischio-rectal  fossa,  425. 

region,  425. 
Isthmus  of  fauces,  55. 

Jaboulay  and  Braun,  gastro-enterostomy,  278. 
Jaw-bone,  lower,  53  (see  "Lower  jaw"). 

upper,  53  (see  "Upper  jaw-bone"). 
Jejunum,  249. 

Keen  bone  forceps,  333. 

Kidney,  abscess  of,  operation  for,  410. 

absence  of  one,  403. 

capsule  of,  403. 

decortication  of,  412. 

extirpation  of,  411. 

fixation  of  (see  "Nephropexy"). 

floating,  403. 

incision  into,  410. 

movable,  403. 


Kidney,  stone  in,  operation  for,  411. 

surgical  anatomy  of,  403. 
Knee-joint,  amputation  of  leg  at,  Carden,  51S. 
Gritti-Stokes,  520. 
Stephen  Smith,  516. 
bursa?  adjacent  to,  515. 
resection  of,  Textor  incision,  538. 

Volkmann  incision,  543. 
surgical  anatomy  of,  513. 
Knot,  slip,  12. 
square,  12. 
surgeon's,  12. 
Kocher,  amputation  of  tongue,  159. 

pylorectomy,  241. 
Kraske,  amputation  of  rectum,  360. 
resection  of  rectum,  353. 
sacral  route  to  reach  rectum,  353. 
Kronlein's  modification  of  Liicke's  operation, 
79. 

Laminectomy,  332. 

Langenbeck,  extirpation  of  tongue,  163. 

formation  of  lower  lip,  114. 

incision  for  resection  of  upper  jaw,  65. 
Laplace  forceps,  264. 

anastomosis,  end-to-end,  with,  264. 
lateral,  with,  272. 

gastro-enterostomy  with,  283. 
Large  intestine  (see  "Intestine"). 

anastomosis  (see  "Intestinal  anastomosis"). 
Laryngeal  region,  134. 
Laryngectomy,  148. 
Laryngotomy,  transverse,  146  (see  also  "Thy- 

rotomy"). 
Larynx,  extirpation  of,  148. 

of  half,  152. 
Lata,  fascia,  482  (see  "Fascia"). 
Lateral    anastomosis    (see    "Intestinal    anas- 
tomosis"). 

implantation  after  resection  of  caecum,  298. 
Lateral  lithotomy,  433. 

nasal  clefts,  96. 
process,  84. 

pectoral  region,  177. 

sinus,  22. 

sternal  line,  171. 
Le  Fort,  exarticulation  of  foot,  509. 
Leg,  492. 

amputation  of,  510. 
with  lateral  hooded  flaps,  510. 

exarticulation  at  knee-joint,  Carden,  518. 
Gritti-Stokes,  520. 
Stephen  Smith,  516. 

varicose  veins  of,  ligation,  497. 
Lembert  suture,  16. 
Ligament,  Colles's  (triangular),  364. 

Gimbernat's,  365-379. 

ilio-pectineal,  374-379. 

Poupart's,  364,  379. 

pubic,  of  Cooper,  372,  374,  379. 

sacro-sciatic,  greater  and  lesser,  483. 

triangular  (Colles's),  364. 

triangular  (perineum),  427,  429. 
Ligamenturu  dentatum,  220. 

nucha?,  120. 
Ligation  of  arteries  (see  "Artery"). 

preliminary,  to  control  hemorrhage,  8. 

of  varicose  veins  of  leg,  497. 
Ligature,  control  of  hemorrhage  by,  11. 
Line,  axillary,  171. 

lateral  sternal,  171. 

mammary,  171. 

midsternal,  171. 

parasternal,  171. 

scapular,  172. 
Linea  alba,  209. 
Lingual  triangle,  127. 
Lip,  lower,  clefts  of,  98. 
excision  of,  111. 


556 


INDEX. 


Lip,  restoration  of,  112. 
Bruns  method,  113. 
Dieffenbach-Jaesche,  112. 
Estlander,  115. 
Langenbeck,  114. 
upper,  median  clefts  and  notches  of,  95. 
restoration  of,  116. 
Lips,  operations  upon,  111. 
surgical  anatomy  of,  54. 
Lisfranc  amputation  of  foot,  501. 

joint,  499. 
Lithotomy,  lateral,  433. 

median,  432. 
Little  toe,  exarticulation  of,  500. 
Liver,  incision  into  (see  "Hepatotoniy"). 
injuries  of,  315. 

resection  of  part  of  (see  "Hepatectomy"). 
surgical  anatomy  of,  310. 
Longitudinal  sinus,  22. 
Lower  anterior  pectoral  region,  177. 
Lower  jaw,  53. 
median  clefts  of,  98. 
resection  of  entire  body  of,  75. 
of  half  of  body  of,  73. 
of  part  of  body  in  continuity,  75. 
not  in  continuity,  76. 
Liicke's  operation,  Kronlein's  modification,  79. 
Lumbar  fascia,  217. 

puncture,  334. 
Lung,  193. 
decortication  of  (see  "neurectomy"), 
limits  of,  193. 
root  of,  192. 

Macewen,  osteotomy,  547. 
Malgaigne  operation  for  harelip,  101. 
Mammary  line,  171. 

region,  175. 
Mandibular  arch,  83. 
Mastoid  antrum,  40. 
drilling  into,  46. 
to  open  and  drain,  46. 

pneumatic,  40. 

region,  surgical  anatomy,  39. 
Maxillary  bone,  inferior  (see  "Lower  jaw"), 
superior  (see  "Upper  jaw-bone"). 

process,  inferior,  83. 
superior,  83. 
Maydl,  colostomy,  292. 
McBurney,  cholecystostomy,  319. 

incision,  225,  Fig.  91. 
McBurney's  point,  286. 
McGill-Fuller  prostatectomy,  433. 
McGraw's  intestinal  anastomosis,  271. 

rubber  suture  gastro-enterostomy,  281. 
McLean  anastomosis  forceps,  264. 
Meckelii,  cavum,  35. 
Meckel's  ganglion,  64. 
Median  lithotomy,  432. 

nerve,  445. 
Mediastinum,  177. 

contents  of,  177. 
Mesentery,  250. 

wounds  of,  252. 
Metacarpo-phalangeal  joints,  450. 

exarticulation  of  finger  at,  452. 
Microcephalia,  craniectomy  for,  29. 
Middle  ear,  43. 

fossa  of  skull,  30. 
extradural  abscess  in,  50. 

meningeal  artery,  hemorrhage  from,  25. 

nasal  process,  84. 
Midsternal  line,  171. 
Mirault  operation  for  harelip,  102. 
Mitral  valve,  182. 
Mohrenheim  fossa,  174. 
Mounsell,    end-to-end   intestinal   anastomosis, 

259. 
Mouth,  54. 


Mouth,  floor  of,  56. 

roof  of,  55. 
Mouth-gag,  Whitehead,  108. 
Murphy       button,       cholecysto-duodenostomy 
with,  325. 
gastro-enterostomy  with,  280. 
intestinal  anastomosis  with,  261-271. 
Muscle,  bulbo-cavernosus,  426. 

compressor    urethras    (see    "M.    transversus 
perinei"). 

erector  spina?,  216. 

external  oblique,  208. 
aponeurosis  of,  209,  364. 

external  pterygoid,  60. 

gluteus  maximus,  482. 

iliacus,  218. 

ilio-psoas,  373. 

internal  oblique,  209. 

internal  pterygoid,  64. 

latissimus  dorsi,  215. 

levator  anguli  scapulae,  216. 

levator  ani,  428-429. 

masseter,  59. 

occipito-frontalis,  19. 

pectoralis  major,  173. 

pectoralis  minor,  173. 

psoas,  218. 

quadratus  lumborum,  217. 

rectus,  210. 

rhomboideus,  216. 

sphincter  ani  (internal  and  external),  341. 
dilatation  of,  342. 

splenius,  216. 

sterno-hyoid,  132. 

sterno-mastoid,  120. 

sterno-thyroid,  132. 

subclavius,  173. 

subcostales,  169. 

temporal,  20. 

transversalis  abdominis,  210. 

transversus  perinei,  427. 

trapezius,  215. 

triangularis  sterni,  169. 
Muscles,  intercostal,  169. 

of  back,  215. 

of  chest  wall,  169. 
Musculo-spiral  nerve,  445. 

Nasal  clefts,  lateral,  96. 

process,  lateral,  84. 
middle,  84. 
Neck,  back  of,  120. 

blood-vessels  of,  136. 

front  of,  129. 

side  of,  120. 

surgical  anatomy  of,  118. 
Nelaton  operation  for  harelip,  100. 
Nephrectomy,  411. 
Nephrolithotomy,  411. 
Nephropexy,  404. 

Edebohls,  407. 
Nephrotomy,  410. 
Nerve,  anterior  crural,  489. 

anterior  tibial,  494. 

auriculo-temporal,  59,  63. 

facial,  45,  52,  59. 

fifth  (trifacial),  33. 
division    of    branches    at    base    of    skull, 

Kronlein-Liicke,  79. 
infericr  maxillary  branch,  63. 
superior  maxillary  branch,  63. 

glosso-pharyngeal,  58. 

gustatory,  58. 

hypoglossal,  58. 

lingual,  58. 

median,  445. 

musculo-spiral,  445. 

posterior  tibial,  495.  , 

sacro-sciatic,  stretching,  483. 


INDEX. 


557 


Nerve,  suture  of,  15,  479. 

trifacial  (see  fifth,  above). 

ulnar,  445. 

vagus  (see   "Nerves,    pneumogastric"). 
Nerves,   inferior  recurrent  laryngeal,  134,  184. 

of  neck,  superficial,  122. 

of  tongue,  58. 

phrenic,  184. 

pneumogastric,  183. 
Neural  tube,  80. 

Oblique  facial  clefts,  86-96. 
Obturator  fascia,  429. 

foramen,  380. 
Occipital  triangle,  127. 
GEsophago-duodenostomy,  245. 
CEsophago-enterostomy,  245. 
Oilsophagostomy,  153. 
CEsophagotomy,  external,  152. 
CEsophagus,  133,  185. 

relations  of,  186. 

stricture    of,    operation    for    (see    "Gastrot- 
omy,"  228. 
O'Hara  forceps,  266. 

anastomosis,  end-to-end,  with,  266. 
lateral,  with,  272. 

gastro-enterostomy  with,  284. 
Olfactory  groove,  84. 
Ophthalmic  nerve  (see  "Fifth  nerve"). 
Oral  pit,  82. 

plate,  80. 
Orbito-nasal  cleft,  86-96. 
Osteoclast,  5. 
Osteotomy  (Macewen),  547. 

Palate,  55. 

cleft,  93. 
operation  for,  107. 

formation  of,  88. 
Pampiniform  plexus,  394. 
Pancreas,  operations  upon,  332. 

surgical  anatomy  of,  331. 
Parasternal  line,  171. 
Parotid  gland,  59. 
Patella,  suture  of,  548. 
Pectineal  fascia  (pubic  portion  of  fascia  lata), 

379. 
Pectoral  region,  lateral,  177. 
lower  anterior,  177. 
upper  anterior,  172. 
Pelvic  cavity  (from  within),  428. 

floor   (from  within),  429. 
Pelvis,  floor  of  (from  without  inward),  424. 
Penis,  amputation  of,  422. 

surgical  anatomy  of,  418. 
Pericardium,    178. 
Pericranium,  20. 
Perineal  fascia,  deep,  427. 
superficial,  424. 

section  with  guide,  430. 
without  guide,  431. 
Perineum,  surgical  anatomy  of,  426. 
Peritoneum,  parietal,  211. 
Phalango-phalangeal  joints,  450. 

exarticulation  of  fingers  at,  450. 
Pharyngeal  membrane,  85. 
Phimosis,  operations  for,  419. 
Phrenic  nerves,  184. 
Pia  mater,  23,  220. 
Piles  (see  "Hemorrhoids"). 
Pirogoff  exarticulation  of  foot,  507. 
Plate,  frontal,  83,  84.  87. 
Pleura,  188. 

anterior  edge  of,  189. 

dome  of,  191. 

excision  of,  203. 

lower  edge  of,  190. 
neurectomy,  fowler,  203. 
Popliteal  space,  491. 


Posterior  triangle  oj.  neck,  122. 
Poupart's  ligament.  364,  379. 

space  beneath,  373. 
Prasvisceral  space,  119. 
Prepuce,  operations  upon,  419. 
Process,  frontal,  83,  84,  87. 

inferior  maxillary,  83. 

infundibular,  367. 

lateral  nasal,  84-87. 

mastoid  (see  "Mastoid  region"). 

middle  nasal,  84-87. 

superior  maxillary,  83. 
Prostate  gland,  428. 
Prostatectomy,  Alexander,  434. 

McGill-Fuller,  433. 
Prostatotomy,  Bottini,  435. 
Pterygo-maxillary  region,  58. 
Pubic  ligament  of  Cooper,  372,  374-379. 

portion  of  fascia  lata,  372. 
Pulmonary  valve  (orifice),  181. 
Purse-string  suture,   Murphy  button,   279,   325. 
Pylorectomy,  237. 

Billroth,  237. 

Kocher,  241. 

use  of  Murphy  button,  241. 
Pyloroplasty,  Heinecke  and  Mikulicz,  231. 
Pylorus,  resection  of  (see  "Pylorectomy"). 

Rectal  wall,  excision  of  part  of,  346. 

polypi,  348. 
Rectum,  amputation,  Kraske,  361. 

Volkmann,  348. 
blood-supply  of,  341. 
resection  of,  Dieffenbach,  351. 

Kraske,  353. 
sacral  route  to  expose,  Kraske,  353. 
surgical  anatomy  of,  338-339. 
Regio  abdominis  lateralis  dextra  and  sinistra, 
213. 
epigastrica,  213. 

hypochondriaca,  dextra  and  sinistra,  213. 
inguinalis,  213. 
mesogastrica,  213. 
pubica,  213. 
umbilicus,  213. 
Region,  anterior  femoral,  485. 
clavicular,  173. 
femoral,  372. 

from  within  abdomen,  378. 
gluteal,  482. 
infraclavicular,  174. 
infrahyoid,  130. 
inguinal,  363. 

from  within  abdomen,  375. 
ischio-rectal,  425. 
laryngeal,  134. 
lateral  pectoral,  177. 
lower  anterior  pectoral,  177. 
mammary,  175. 
mastoid,  39. 
pterygo-maxillary,  58. 
sternal,  172. 
sterno-mastoid,  123. 
suprahyoid,  130. 
suprasternal,  135. 
upper  anterior  pectoral,  172. 
Regnoli-Billroth  amputation  of  tongue,  161. 
Remak,  rachenhaut  of,  85. 
Resection  of  ankle-joint,  Koenig,  533. 

Langenbeck-Hueter,  529. 

Lauenstein,  535. 

Mikulicz-Wladimirow,  536. 

with  extirpation  of  astragalus,  532. 
of  caecum,  295. 
of  elbow-joint,  474. 
of  hip-joint,  Langenbeck  incision,  543. 

Anthony  White  incision,  545,  Fig.  225. 
of  intestine  (see  "Enterectomy"). 
of  knee-joint,  Textor  incision,  538. 


553 


INDEX. 


Resection    of   knee-joint,    Volkmann    incision, 
543. 
of  lower  jaw,  half,  70. 
entire  body  of,  75. 
half  of  body  of,  73. 
part  of  body  in  continuity,  75. 
not  in  continuity,  76. 
of  pylorus  (see  "Pylorectomy"). 
of  rectum  (see  "Rectum"), 
of  rib,  201. 

of  skull,  temporary,  26. 
of  shoulder-joint,  476. 
of  upper  jaw,  64. 

of  both,  69. 
of  wrist-joint,  472. 
Retrovisceral  space,  119. 
Rib,  first,  167. 

resection  of  (thoracotomy),  201. 
Ribs,  167. 

Ring,  crural,  375-380. 
inguinal,  external,  364. 
internal,  366,  377. 
Rose  position,  9. 

Rose-Andrews,   extirpation  of  Casserian  gan- 
glion, 76. 
Roser,  dorsal  section,  420. 

Sacral  route,  rectum,  353. 
Sacro-sciatic  ligaments,  483. 
Sacrum,  338. 
Saphenous  opening,  372,  485. 

vein,  internal,  485. 
Scalp,  19. 
Scapular  line,  172. 
Scarpa's  triangle,  486. 
Schlatter,  gastrectomy,  244. 
Schleich  infiltration  method,  3. 
Sciatic  nerve,  stretching,  483. 
Scrotum,  394. 

Sedili^t,  extirpation  of  tongue,  162. 
Seminal  vesicles  (see  "Vesiculae  seminales"). 
Serous  surfaces,  suture  of,  16. 
Shoulder-joint,  exarticulation  at,  deltoid  flap, 
469. 
Spence  method,  465. 
with  Esmarch  constrictor,  467. 

resection  of,  474. 

surgical  anatomv  of,  463. 
Side  of  neck,  120. 

Side-to-side  anastomosis   (see  "Intestinal  an- 
astomosis"). 
Sigmoid  flexure,  anatomy  of,  288. 
resection  of,  298. 

sinus,  39. 
thrombosis  of,  48. 
Sinus,  cavernous,  22,  33. 

frontal,  21. 

lateral,  22. 

longitudinal,  22. 

sigmoid,  39. 
thrombosis  of,  48. 
Skin,  suture  of,  13. 

intracuticular,  14. 
Skull,  20. 

middle  fossa,  30. 

temporary  resection  of,  26. 

trephining  for  depressed  fracture,  23. 
Slip  knot,  12. 
Small  intestine,  247  (see  also  "Intestine"). 

anastomosis  (see  "Intestinal  anastomosis"). 

blood-supply  of,  251. 

surgical  anatomy  of,  247. 
Smith   (Stephen),  amputation  of  leg  at  knee- 
joint,  516. 
Soft  parts,  division  of,  4. 
Space,  femoral,  374-379. 

prsevisceral,  119. 

retrovisceral,  119. 

subarachnoid,  brain,  23 


Space,  subarachnoid,  spinal  cord,  220. 
subdural,  cranium,  23. 

vertebral,  220. 
vascular,  119. 
Spence,    exarticulation    of    arm    at    shoulder- 
joint,  465. 
Spermatic  cord,  365-393. 

fascia,  394. 
Sphincter  ani  muscles,  341. 

dilatation  of,  342. 
Spina  supra  meatum,  40. 
Spinal  column,  218. 

cord,  219. 
dura  mate'r  of,  220. 
pia  mater  of,  220. 
Spleen,  excision  of,  330. 

incision  into,  329. 

surgical  anatomy,  328. 
Splenectomy,  330. 
Spleno-maxillary  fossa,  62. 
Splenotomy,  329. 
Square  knot,  12. 

Ssabanajew-Franck  gastrostomy,  233. 
Staphylorrhaphy,  108. 
Stenson's  duct,  5u.  59. 
Sternal  region,  172. 
Sterno-mastoid  region,  123. 
Sternum,  168. 
Stomach,  221. 

closure  of  wounds  of  (gastrorrhaphy),  237. 

excision  of  (see  "Gastrectomy"). 

foreign  bodies  in,  operation  for,  228. 

incision  into,  228. 

incisions  to  expose,  224. 

operations  upon,  226. 

surgical  anatomy  of,  221. 
Stricture,   urethral,   perineal  section  for,   430- 
431. 
suprapubic  cystotomy  for  impassable,  432. 
Styptics,  10. 

Subarachnoid  space,  brain,  23. 
spinal  cord,  220. 

injection    of    cocain,    3    (see    also    "Lumbar 
puncture"). 
Subclavian  triangle,  128. 
Subdural  space,  cranium,  23. 

vertebral,  220. 
Sublingual  glands,  57. 
Submaxillary  triangle,  126. 
Submental  triangle,  130. 
Superficial  fascia  of  groin,  362. 
Superior  maxilla  (see  "Upper  jaw-bone"). 
Superior  maxillary  branch  of  fifth  nerve,  63. 

process,  83. 
Suprahyoid  region,  130. 
Suprapubic  cystotomy,  415. 
Suprasternal  region,  135. 
Surgeon's  knot,  12. 
Suture,  Cushing,  17. 

Lembert,  16. 

material,  13. 

of  bladder,  18. 

of  bone,  15. 

of  bowel,  16. 

of  cartilage,  15. 

of  muscle,  14. 

of  nerve,  15,  480. 

of  patella,  548. 

of  serous  surfaces,  16. 

of  skin,  13. 
intracuticular,  14. 

of  tendon,  15,  479. 

of  tissues,  13. 
Syme,  exarticulation  of  foot,  506. 

Tampon  cannula,  Trendelenburg,  142. 
Tamponade  to  control  hemorrhage,  10. 
Tarsus,  498. 
Tear-duct,  86. 


INDEX. 


Teeth,  development  of,  89. 
Temporal  fascia,  19. 
Temporary  resection  of  skull,  26. 
Temporo-sphenoidal  abscess,  51. 
Tendon,  suture  of,  15,  479. 
Tenotomy,  496. 
of  flexor  longus  digitorum,  496. 
of  tendo  Achillis,  496. 
of  tibialis  posticus,  496. 
Testes,  descent  of,  369. 
Testis,  394. 

extirpation  of,  401. 
Thigh,  482. 
amputation  of,  521. 

exarticulation  of,  at  hip-joint  (Wyeth),  526. 
with  preliminary  ligation  of  common  fem- 
oral, 489. 
Thoracectomy  (Estlander),  202. 
Thoracentesis,  201. 
Thoracic  aorta,  187. 
duct,  188. 

wall,  muscles  of,  169. 
Thoracotomy,  201. 

Thorax,  aspiration  (see  "Thoracentesis"), 
fasciae  of,  169. 
resection  of  wall  of,  202. 
skeleton  of,  166. 
tapping  (see  "Thoracentesis"). 
Thrombosis  of  sigmoid  sinus,  48. 
Thymus  body,  182. 
Thyro-hyoid  membrane,  132. 
Thyroid  gland,  134. 
Thyrotomy,  146. 
Toe,  amputation,  500. 
Toe-nail,  ingrowing,  operation,  501. 
Tongue,  57. 
amputation,  with  division  of  lower  jaw,  162. 
Kocher,   with  preliminary  ligation  of  lin- 
gual, 159. 
Regnoli-Billroth,  161. 
Whitehead,  164. 
clefts  of,  98. 
development  of,  89. 

extirpation  of,  with  division  of  lower  jaw,  162. 
Billroth,  164. 
Langenbeck,  163. 
of  half,  Whitehead,  164. 
Sedillot,  162. 
nerves  of,  58. 
Torsion,  11. 
Trachea,  184. 

tampon  of,  142. 
Tracheotomy,  142. 
high,  143. 
low,  144. 
median,  145. 
Transversalis  fascia,  211. 
Transverse  colon,   anatomy  of,  287. 

facial  cleft,  87. 
TrendelenDurg  position,  8. 

tampon  cannula,  142. 
Trephine,  removal  of  button  of  bone,  28. 
Trephining,  23. 
for  depressed  fracture  of  skull,  23. 
for  hemorrhage  from  middle  meningeal,  25. 
for  intracranial  hemorrhage,  25. 
Triangle  of  neck,  anterior,  122. 
inferior  carotid,  123. 
lingual,  127. 
occipital,  127. 
posterior,  122. 
Scarpa's,  486. 
subclavian,  128. 
submaxillary,  126. 
submental,  130. 
superior  carotid,  125. 
Triangular  ligament  (groin),  364. 

(perineum),  427-428. 
Tricuspid  valve,  182. 


Trifacial  nerve  (see  "Fifth  nerve"). 
Tympanum,  43. 

Upper  anterior  pectoral  region,  172. 
Upper  jaw-bone.  53. 

resection  of,  64. 
Upper  jaw-bones,  resection  of  both,  69. 
Upper  lip,  median  clefts  and  notches  of,  95. 

restoration  of,  116. 
Uranoplasty,  109. 

Urethra,  perineal  section  for  stricture  of,  430. 
suprapubic  cystotomy  for  impassable  strict- 
ure of,  432. 
Urethrotomy,  external,  with  guide,  430. 

without  guide,  431. 

Vaginal  process  of  peritoneum,  370. 
"Valve,  aortic,  181. 

mitral,  182. 

pulmonary,  181. 

tricuspid,  182. 
Varicocele,  open  operation,  395. 
Varicose  veins,  ligation  of,  497. 
Vas  deferens,  393-395. 

Vascular  space,  deep  cervical  fascia,  119. 
Vein,  anterior  jugular)  121. 

axillary  (see  "Artery,  axillary"). 

azygos,  187. 

basilic,  442. 

external  jugular,  121. 

facial,  126. 

hemiazygos.  188. 

inferior  thyroid,  135. 

internal  jugular,  139. 
ligation  and  excision  of,  49. 

internal  saphenous,  485. 

subclavian,  141. 

temporal,  60. 

temporo-facial,  60. 
Velpeau  incision  for  resection  of  upper  jaw, 

65,  Fig.  19. 
Vermiform   appendix    (see    "Appendix  vermi- 

formis"). 
Vertebrae,  dorsal,  167. 
Vertebral  column,  218. 
Vesicle  of  forebrain,  81. 
Vesiculae  seminalis,  428. 
Vicious  circle  (gastro-enterostomy),  279. 
Visceral  arches,  82. 

clefts,  82. 
Vogt's  lines,  26. 
Volkmann,  amputation  of  rectum,  348. 

operation  for  hydrocele,  398. 
Von  Bergmann  operation  for  hydrocele,  399. 
Von  Grafe  operation  for  harelip,  100. 
Von  Hacker,  gastro-enterostomy,  276. 

gastrostomy,  232. 

incision,  224. 

Wagner,  temporary  resection  of  skull,  26. 
Weber's  incision  for  resection  of  upper  jaw, 

64. 
Wellenschnitt,  Dieffenbach's,  103,  105,  116. 
Wharton's  duct,  57. 
Whitehead  amputation  of  tongue,  164. 

mouth-gag,  108,  Fig.  59. 
Wilde's  incision,  46. 
Witzel,  gastrostomy,  235. 
Woelfler.  gastro-enterostomv,  272. 

suture  of  gut,  258,  Fig.  108. 
Wrist-joint,  exarticulation  of  hand,  Dubrueil, 
456. 

resection  of,  472. 

surgical  anatomy  of,  455. 
Wyeth,    exarticulation    of   thigh   at   hip-joint, 

526. 
Wyeth's  pins,  526. 

Zygomatic  fossa,  61. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 

RD32M17C.1 

Surgical  anatomy  and  operative  surgery 


